Superior Court Children'S Room Registration Form

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SUPERIOR COURT OF CALIFORNIA
COUNTY OF FRESNO
CHILDREN’S WAITING ROOMS
SITE: ____________________________
SUPERIOR COURT CHILDREN’S ROOM REGISTRATION
DATE: _______________
PARENT LOCATION: _____________
IN: _______ OUT: _______
SIGNATURE: _________________________________
IN: _______ OUT: _______
SIGNATURE: _________________________________
ID VERIFICATION:
CA Driver’s License
Other:_______________________
NAME(S) OF CHILD(REN):
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
__________________________/_______/_______________________ ______ _____
First
MI
Last
Age
M/F
List additional children on back
NAME(S) OF PARENT(S)/ADULTS REGISTERING/PICKING UP CHILD:
______________________________/_______/_______________________________
First
MI
Last
__________________________/_______/______________/_________/________
Street
Apt #
City
State
Zip
______________________________________
________________________________
Phone number
Alternate
______________________________/_______/_______________________________
First
MI
Last
______________________________/_______/_______________________________
First
MI
Last
List additional adults on back
EMERGENCY CONTACT INFORMATION
__________________________/___________________ ______________________
First
Last
Phone number
Does the registered child(ren) have any allergies, asthma or contagious conditions:
Please list child’s name and condition(s):
______________________________________________________________________
Consent for Emergency Medical Treatment
________As the parent/legal guardian, agency representative or responsible adult, I hereby give consent to the
Central Valley Children’s Services Network/Superior Court Children’s Waiting Room facility to provide all
emergency medical treatment for child(ren)’s list above. This treatment or care may be given under whatever
conditions are necessary to preserve the life, limb or well being of the above named child(ren).
_______In addition, I give my permission for my child(ren) to have his/her photograph taken while in the
SCCWR:
I have been given a copy of the Parent Rules and have read and agree to the rules.
________________________________________________
____________________________
Parent/Legal Guardian/Agency Representative or Adult Signature
Date

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