South Carolina Department of Social Services
Child Care Regulatory Services

General Record and Statement of Child's Health for Admission to Child Care Facility

This form is to be completed for each child at the time of enrollment in the child care facility, updated as needed when changes occur, and maintained on file at the facility

GENERAL INFORMATION: (to be completed by Parent or Guardian)
Name of Facility:
County:*
Address:
City, State, Zip Code:
Child Name:*
-*
-
-

What program option are you registering for?*

Center:*
Date of birth:*
Enrollment Date:
Child's Current Home Address:
City, State, Zip Code:
Parent/Guardian's Full Name:*
Primary Phone:
Home Phone:
Work Phone:
Parent/Guardian's Full Name:
Home Phone
Primary Phone:
Work Phone:
You must have two individuals who have the authority to obtain emergency medical treatment for the child.
1. Person responsible if parent/guardian is unavailable for emergency medical services:
Address(Street Address):
City, State, Zip Code:
Telephone Number(s) :
Family Code Word(s):
2. Person responsible if parent/guardian is unavailable for emergency medical services:
Address(Street Address):
City, State, Zip Code:
Telephone Number(s):
Family Code Word(s):
My Child will regularly attend this facility FROM am/pm TO am/pm
If Child is a drop-in, indicate hours of care: FROM am/pm TO am/pm
Check all days Child will regularly attend this facility:    
   
   
   
   
   
   
Check all meals Child will receive daily:    
   
   
   
   
   
   
HEALTH INFORMATION: (to be completed by Parent or Guardian)
Family Physician or Health Resource:
Street Address:
City, State, Zip Code:
Telephone:
Emergency Care Provider:
Street Address:
City, State, Zip Code:
Telephone:
Dental Care Provider:
Street Address:
City, State, Zip Code:
Telephone:
Health Insurance Provider:
Certifcate of immunzation:    
   
   
My child has the following health conditions such as allergies, asthma, diabetes, epliepsy, etc. and or take the following medications on a regular basis.
Additional Comments:
I certify to the best of my knowledge:
Is in good mental and physical health and able to participate in the child care program at:
Parent Name:
Date:
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Parent Signature
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