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Get SC DSS 2900 2010-2024

1. Person responsible if parent/guardian unavailable for emergency medical services Full Name Relationship Telephone Number s Family Code Word s Is Child currently enrolled in school 5K up to 6 years old My Child will regularly attend this facility FROM Yes am/pm TO If Child is a drop-in indicate hours of care FROM Afternoon Snack Dinner Check all days Child will regularly attend this facility Check all meals Child will receive daily No Mon Tue Meals are not offered Wed Breakfast Thurs Fri Sat Morning Snack Evening Snack HEALTH INFORMATION to be completed by Parent or Guardian Family Physician or Health Resource Name Telephone Emergency Care Provider Emergency Facility Name DSS Form 2900 MAR 10 Edition of OCT 07 is obsolete. Reset 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 Select County. County Address City State Zip Street Address no Post Office Boxes Child s Name Last First Middle Initial Date of Birth Nick Name Enrollment Date Child s Current Home Address Parent/Guardian s Full Name Home Phone Work Phone Other Phone You must have two individuals who have the authority to obtain emergency medical treatment for the child. Sun Lunch Dental Care Provider Health Insurance Provider Certificate of Immunization N/A Please explain My child has the following health conditions such as allergies asthma diabetes epilepsy etc* and/or takes the following medications on a regular basis Additional Comments I certify that to the best of my knowledge is in good mental and physical health and able to participate in the child care program at Name of Child Care Facility Signature Date Director/Operator/Staff Designee PAGE 2. Reset 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 Select County. County Address City State Zip Street Address no Post Office Boxes Child s Name Last First Middle Initial Date of Birth Nick Name Enrollment Date Child s Current Home Address Parent/Guardian s Full Name Home Phone Work Phone Other Phone You must have two individuals who have the authority to obtain emergency medical treatment for the child. .

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