Dss Form 2900 PDF Details

Dss Form 2900 is a document used to request or provide information about an individual receiving Temporary Assistance for Needy Families (TANF) benefits. The form can be used by caseworkers, attorneys, employers, and other interested parties. The purpose of the form is to provide information about an individual's eligibility for benefits and their current situation. Completed forms can be submitted to state agencies or courts as needed.

You will discover additional information relating to the dss form 2900 by looking through the table our team prepared for you.

QuestionAnswer
Form NameDss Form 2900
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdss 2900, dss form child child care, south carolina form child care, dss form 2900

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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:

 

Select County ...

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address – no Post Office Boxes

 

 

 

 

City, State, Zip

 

Child’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last

 

First

Middle Initial

Nick Name

Date of Birth:

 

 

 

 

Enrollment Date:

 

 

 

 

 

Child’s Current Home Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

City, State, Zip

 

Parent/Guardian’s Full Name:

 

 

 

 

 

 

 

 

 

 

 

Home Phone:

 

 

 

 

 

Work Phone:

 

 

 

 

Other Phone:

 

 

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.

1. Person responsible if parent/guardian unavailable for emergency medical services:

 

 

Full Name

Relationship

Address:

 

 

 

 

 

 

Street Address

City, State, Zip

Telephone Number(s):

 

Family Code Word(s):

 

2. Person responsible if parent/guardian unavailable for emergency medical services:

 

 

 

 

Full Name

 

 

 

 

 

 

 

 

 

 

Relationship

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

City, State, Zip

 

Telephone Number(s):

 

 

 

 

 

 

 

 

 

 

Family Code Word(s):

 

 

Is Child currently enrolled in school? (5K up to 6 years old) „ Yes

„ No

 

 

 

 

 

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:

„ Mon „ Tue

„ Wed

„ Thurs „ Fri „ Sat

„ Sun

Check all meals Child will receive daily:

„ Meals are not offered

„ Breakfast „ Morning Snack

„ Lunch

„ Afternoon Snack „ Dinner „ Evening Snack

 

 

 

 

 

 

 

 

 

HEALTH INFORMATION: (to be completed by Parent or Guardian)

 

 

 

 

 

 

 

 

 

Family Physician or Health Resource:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

City, State, Zip

 

 

 

 

 

 

 

Telephone

 

Emergency Care Provider:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Facility Name

Street Address

City, State, Zip

Telephone

DSS Form 2900 (MAR 10) Edition of OCT 07 is obsolete.

Dental Care Provider:

 

 

 

Name

 

 

 

 

Street Address

City, State, Zip

Telephone

Health Insurance Provider:

 

 

 

 

Certificate of Immunization:

„ Yes „ No „ 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

Child’s Name

is in good mental and physical health and able to participate in the child care program at

 

Name of Child Care Facility

Signature:

 

Date:

 

 

Parent or Guardian

 

 

Signature:

 

Date:

 

 

Director/Operator/Staff Designee

 

 

DSS Form 2900 (MAR 10)

PAGE 2

How to Edit Dss Form 2900 Online for Free

It won't be hard to complete south carolina form child care applying our PDF editor. This is how it is possible to quickly prepare your form.

Step 1: Initially, choose the orange "Get form now" button.

Step 2: When you have accessed the south carolina form child care editing page you may find the different options you can perform relating to your template in the top menu.

Type in the data requested by the program to get the form.

example of fields in south carolina dss facility

Jot down the details in the ParentGuardians Full Name, Home Phone, Work Phone, Other Phone, You must have two individuals who, Person responsible if, Full Name Relationship, Address, Telephone Numbers, Street Address, City State Zip, Family Code Words, Person responsible if, Full Name Relationship, and Address field.

Finishing south carolina dss facility stage 2

It's essential to write down some data inside the space HEALTH INFORMATION to be completed, Family Physician or Health Resource, Name, Street Address Emergency Care, City State Zip, Telephone, Emergency Facility Name, Street Address, City State Zip, Telephone, and DSS Form MAR Edition of OCT is.

Filling out south carolina dss facility part 3

The area Dental Care Provider, Street Address, Health Insurance Provider, Name, City State Zip, Telephone, Certificate of Immunization, My child has the following health, Additional Comments, I certify that to the best of my, Childs Name, and is in good mental and physical will be where you insert each side's rights and obligations.

south carolina dss facility Dental Care Provider, Street Address, Health Insurance Provider, Name, City State Zip, Telephone, Certificate of Immunization, My child has the following health, Additional Comments, I certify that to the best of my, Childs Name, and is in good mental and physical fields to insert

Finish by reading the next sections and preparing them accordingly: Signature, Signature, Parent or Guardian, DirectorOperatorStaff Designee, Date, and Date.

Filling out south carolina dss facility step 5

Step 3: As soon as you are done, press the "Done" button to transfer the PDF file.

Step 4: In order to prevent all of the complications in the future, be sure to get a minimum of a few copies of your file.

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