Form Ccl 358 - Kansas Health History For Children And Youth Attending School Age Programs - Department Of Health And Environment
ADVERTISEMENT
1
2CCL. 358
Kansas Department of Health and Environment
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax (785) 559-4244
Website:
HEALTH HISTORY FOR CHILDREN AND YOUTH ATTENDING SCHOOL AGE PROGRAMS
As required by K.A.R. 28-4-590(d) (1), each operator shall obtain a health history for each child or youth, on a form supplied by the
department or approved by the secretary. Each health history is to be maintained in the child’s or youth’s file on the premises. As
required by K.A.R. 28-4-590(d)(2), each operator shall require that each child or youth attending the program has current immunizations
as specified in K.A.R. 28-1-20 or has an exemption for religious or medical reasons.
Complete one form for each child or youth attending the School Age Program.
Gender
Date of Birth
First day at this program:
First and Last Name of the Child or Youth
(M or F)
(MM/DD/YYYY)
(MM/DD/YYYY)
First and Last Name of the Child’s or Youth’s Mother or Guardian
Mother/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Mother/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
First and Last Name of the Child’s or Youth’s Father or Guardian
Father/Guardian’s Home Street Address
City
Zip Code
Home Phone #
(
)
Father/Guardian’s Work Place Name & Street Address
City
Zip Code
Work Phone #
(
)
Names and ages of other children in the Child or Youth’s Family (Attach additional page if needed.)
Person(s) authorized to pick up the Child or Youth in
City
Zip Code
Phone Number (during
case of emergency. Include first and last name and
program hours):
Street Address. Attach additional page if needed.
1.
2.
3.
First and Last Name of Physician & Street Address
City
Zip Code
Phone Number
(
)
Name of Hospital Preference in case of emergency.
Yes
No
N/A
Complete the following information about medications for this child or youth.
Will this child or youth need to take any nonprescription or prescription medication during their time at the
program?
If yes above, is there signed permission on file?
ADVERTISEMENT
0 votes
Related Articles
Related forms
Instructions For Form It-241 -i (2012) - Claim For Clean Heating Fuel Credit - New York State Department Of Taxation And Finance
Financial
Instructions For Form It-252 - Investment Tax Credit For The Financial Services Industry - New York State Department Of Taxation And Finance - 2002
Financial
Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs
Legal
Form Acf-196t - Administration For Children And Families - U. S. Department Of Health And Human Services
Legal
Form Hc 201p - Pharmacy Programs Application Form - Vermont Department For Children And Families
Business
Related Categories
Parent category: Legal