DSS Form 2930 "Authorization for Intervention, Therapy and Extracurricular Activities" - South Carolina

What Is DSS Form 2930?

This is a legal form that was released by the South Carolina Department of Social Services - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the South Carolina Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DSS Form 2930 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 2930 "Authorization for Intervention, Therapy and Extracurricular Activities" - South Carolina

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South Carolina Department of Social Services
Child Care Licensing
AUTHORIZATION FOR INTERVENTION, THERAPY AND
EXTRACURRICULAR ACTIVITIES
I authorize
to remove
Name of Person/Entity Providing Activity
/
Name of Child
Child’s Date of Birth
from
and/or its programs from
Name of Child Care Facility
to
on
Time
Time
Dates/Period of Service (See instructions below)
for the purpose of participating in
. I am aware that
Type of Activity
while participating in
, my child will not be supervised
Type of Activity
by a qualified staff person employed by
.
Name of Child Care Facility
I am also aware that,
and its employees
Name of Person/Entity Providing Activity
are not required to adhere to laws governing
Name of Child Care Facility
including, but not limited to laws governing staff to child ratios, supervision, background checks, and educational
training.
Parent/Guardian’s Signature
Date
Child Care Facility Director’s Signature
Date
Person Providing Activity’s Signature
Date
Instructions:
This form must be completed and signed by all parties before providing services or
activities. Beginning and ending dates should be used to show when the service or
activity is being provided. If the service or activity continues for more than a year from
the date it is signed, the form must be renewed.
DSS Form 2930 (JUL 11)
Reset
South Carolina Department of Social Services
Child Care Licensing
AUTHORIZATION FOR INTERVENTION, THERAPY AND
EXTRACURRICULAR ACTIVITIES
I authorize
to remove
Name of Person/Entity Providing Activity
/
Name of Child
Child’s Date of Birth
from
and/or its programs from
Name of Child Care Facility
to
on
Time
Time
Dates/Period of Service (See instructions below)
for the purpose of participating in
. I am aware that
Type of Activity
while participating in
, my child will not be supervised
Type of Activity
by a qualified staff person employed by
.
Name of Child Care Facility
I am also aware that,
and its employees
Name of Person/Entity Providing Activity
are not required to adhere to laws governing
Name of Child Care Facility
including, but not limited to laws governing staff to child ratios, supervision, background checks, and educational
training.
Parent/Guardian’s Signature
Date
Child Care Facility Director’s Signature
Date
Person Providing Activity’s Signature
Date
Instructions:
This form must be completed and signed by all parties before providing services or
activities. Beginning and ending dates should be used to show when the service or
activity is being provided. If the service or activity continues for more than a year from
the date it is signed, the form must be renewed.
DSS Form 2930 (JUL 11)