To submit this form, you can send it by mail to Kansas Department of Health and Environment, Bureau of Family Health Facilities, Child Care Licensing Program, 1000 SW Jackson, Suite 200, Topeka, KS 66612-1274. Additionally, you can fax it to (785) 559-4244. It's advisable to keep a copy of the submitted form for your records. Be sure to complete all sections accurately and provide all required signatures before submission.

Ensure the form is completed annually or whenever there are updates to the child's medical or immunization records. Review and update the form each time your child changes child care facilities or healthcare providers.

This form serves to document the medical history and immunization records of children attending licensed child care facilities in Kansas. By maintaining accurate medical records, child care providers can better manage the health and safety of children in their care. The form facilitates the transfer of important health information when a child moves between care facilities, ensuring continuity of care.

• 1. Child's First Day in Child Care: The starting date for the child in the care facility.
• 2. Child's Name: Full name of the child including first and last names.
• 3. Date of Birth: Child's birth date in MM/DD/YYYY format.
• 4. Gender: The gender of the child.
• 5. Parent/Guardian Information: Includes the name, contact information, and address of the parent or guardian.
• 6. Persons Authorized to Pick Up: Names, addresses and phone numbers of individuals authorized to pick up the child or be contacted in case of emergency.
• 7. Child's Physician: Name, address, and phone number of the child's physician.
• 8. Child's Dentist: Name, address, and phone number of the child's dentist.
• 9. Hospital Preference: Preferred hospital to be contacted in case of emergencies.
• 10. Non-prescription Medications: Approval and details on any non-prescription medications for the child.
• 11. Allergies or Medical Conditions: Any known allergies or medical conditions the child has.
• 12. Major Changes at Home: Any major changes at home that might impact the child’s care.
• 13. Additional Information or Special Instructions: Additional details that will aid the caregiver.
• 14. Parent/Guardian Signature: Signature of the parent/guardian.
• 15. Date: Date the form was completed.
• 16. History of Immunizations: Detailed immunization records, including dates of vaccinations and physician’s signature for any medical exemptions.
• 17. Exemptions from Immunizations: Details on exemptions from immunization laws with physician’s certification or declaration of religious beliefs.
• 18. Child Health Assessment: Assessment completed and signed by a licensed physician or nurse approved to perform child health assessments including physical examination and health history.
• 19. Screening Tests: Details of screening tests conducted, including dates and results for lead, anemia, urinalysis, hearing, and vision.

Failure to submit this form can result in non-compliance with child care facility regulations. It may also lead to inadequate health records for the child, impacting the quality of care they receive.

• Non-compliance: Not submitting the form means the child care facility may not meet regulatory requirements.
• Incomplete Health Records: The child’s health records will be incomplete, which could lead to improper care.
• Emergency Situations: In emergency situations, caregivers may lack critical health information needed to treat the child properly.

• 1. Enrollment: When enrolling a child in a new child care facility.
• 2. Annual Updates: To provide updated health and immunization records annually.
• 3. Change of Care Facility: When transferring a child to a different child care facility.
• 4. Healthcare Updates: To update records when there are changes in the child’s health or immunizations.
• 5. Regulatory Compliance: To ensure the child care facility complies with health and safety regulations.