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Lic 700

The document provides a form for a child care center to collect identification and emergency contact information for a child, including the child's name, address, contact information for parents or guardians, emergency contacts, doctor and dentist information, who is authorized to pick up the child, and notes fields for the director to provide admission and last enrollment dates.

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976 views2 pages

Lic 700

The document provides a form for a child care center to collect identification and emergency contact information for a child, including the child's name, address, contact information for parents or guardians, emergency contacts, doctor and dentist information, who is authorized to pick up the child, and notes fields for the director to provide admission and last enrollment dates.

Uploaded by

fnrmc5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

State of California ­– Health and Human Services Agency California Department of Social Services

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE


CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE


( )

ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE

PARENT / LAST MIDDLE FIRST BUSINESS


AUTHORIZED TELEPHONE
REPRESENTATIVE ( )
NAME
HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME
TELEPHONE
( )

PARENT / LAST MIDDLE FIRST BUSINESS


AUTHORIZED TELEPHONE
REPRESENTATIVE ( )
NAME
HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME
TELEPHONE
( )

PERSON LAST MIDDLE FIRST HOME BUSINESS


RESPONSIBLE TELEPHONE TELEPHONE
FOR CHILD ( ) ( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY


NAME ADDRESS TELEPHONE RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY


PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE
( )

DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE


( )

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?


CALL EMERGENCY HOSPITAL OTHER EXPLAIN: ________________________________

LIC 700 (10/19) (CONFIDENTIAL) Page 1 of 2


State of California ­– Health and Human Services Agency California Department of Social Services

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY


(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN
AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
NAME RELATIONSHIP

TIME CHILD WILL BE PICKED UP


SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY


CHILD CARE HOMES LICENSEE
DATE OF ADMISSION LAST DATE OF ENROLLMENT

LIC 700 (10/19) (CONFIDENTIAL) Page 2 of 2

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