Kansas Department Of Health Form - Medical Record For All Children In Child Care Facilities, Including Provider'S Own Children - Form C
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3Kansas Department of Health and Environment
CCL. 029
Rev. 8/2013
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone (785) 296-1270 Fax (785) 296-0803
Form C
Website:
MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,
INCLUDING PROVIDER’S OWN CHILDREN
Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care
facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child
moves to another licensed child care facility.
LUMC Preschool/CDO
Child’s First Day in Child Care
Name of Child Care Facility
Child’s Name
Date of Birth
Gender
First
Last
MM/DD/YYYY
M/F
Parent/Guardian Information
Parent/Guardian Information
Name
Name
Home Address
Home Address
Street
City
Zip Code
Street
City
Zip Code
Home Phone Number
Home Phone Number
Work Address
Work Address
Street
City
Zip Code
Street
City
Zip Code
Work Phone Number
Work Phone Number
Cell Phone Number
Cell Phone Number
E-mail Address
E-mail Address
Best way to contact
Best way to contact
Names and ages of children in family
Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.
Attach an additional page, if necessary.
Child’s Physician
Phone Number
Child’s Dentist
Phone Number
Hospital Preference (for emergencies)
Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough
syrup, or ointments that can be given by the child care provider?
No
Yes, as follows:
Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for
Emergency Medical Care form CCL. 010.
Allergies
Frequent sore throats/colds
Ear Aches
Asthma
Speech, Visual, Hearing
Diabetes
Epilepsy/Seizures
Other
If yes answered to any above, please provide additional information
Have there been major changes at home that might affect your child in care?
No
Yes, as follows:
Please provide additional information or special instructions that will help the person caring for your child.
Parent/Guardian Signature:_________________________________________Date:_____________
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