Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/exclusion) State Of California - Health And Human Services Agency
Download a blank fillable Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/exclusion) State Of California - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/exclusion) State Of California - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REMOVAL/EXCLUSION)
California State law requires the licensee to notify you that the person whose name appears below has been
removed or excluded from this Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
This person is not permitted to be in the home at any time when children are in care. This
removed/excluded person may be an ex-employee, friend or relative of the licensee. This person has a right
to appeal the exclusion. If he/she is later permitted back into the Family Child Care Home you will be
notified.
The local licensing office listed below maintains a public file on this facility. Parents, domestic partners or
authorized representatives may review the public file for any documents related to this action. You should
know that many documents are protected by confidentiality laws and will not be available for review.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
A C K N O W L E D G M E N T O F
A D D E N D U M T O N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M O VA L / E X C L U S I O N )
This will acknowledge that I, the parent/authorized representative of ______________________,
h a v e r e c e i v e d a c o py o f t h e “ A D D E N D U M TO N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E M OVA L / E X C L U S I O N ) ” f r o m t h e l i c e n s e e o r d e s i g n a t e d r e p r e s e n t a t i ve.
(Parent /Authorized Representative signature is required) .
______________________________________________
_______________________
Signature of Parent/Authorized Representative
Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995B (8/08)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Gastrostomy - Tube Care: Physician's Checklist (child Care Facilities) State Of California - Health And Human Services Agency
Legal
Application For A Child Care Center License - State Of California - Health And Human Services Agency
Legal
Confidential Report Of Suspected Dependandent Adult / Elder Abuse - State Of California - Health And Human Services Agency
Legal
Roster Of Participants - For Vendor Use Only- Ictp Or Ceu Courses - State Of California - Health And Human Services Agency
Legal
Form Cdph 8391 - Report Of Name Or Address Change - State Of California-health And Human Services Agency
Legal
Form Qr 3 - Mid-quarter Status Report For Cash Aid And Food Stamps - 2006 - State Of California - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal