GLEAMNS Human Resources Commission, Inc

GLEAMNS Human Resources Commission, Inc. Post Office Box 1326 Greenwood, South Carolina 29648 Telephone: (864) 223-8434 Telefax: (864) 229-8857

Home Visit Report

Child’s Name: ______Center: ______

Address: ______

Telephone: ______Purpose of Visit: ______

Date/Time: ______Relationship to Child: ______

Others Present: ______

1. Report of child’s progress in cognitive, language, emotional, physical, and social development.

2. Suggestions for home learning activities:

3. Parent’s input to the educational program:

4. Other comments or observations:

This is to verify ______was in my home on ______,

______for the purpose of conducting a home visit.

______Parent’s Signature Staff Member’s Signature

GREENWOOD-LAURENS-EDGEFIELD-ABBEVILLE-MCCORMICK-NEWBERRY-SALUDA (Serving: Fairfield, Lexington, and Richland Counties)

“AN EQUAL OPPORTUNITY EMPLOYER”