Form Lic 9150 - Parent Notification - Additional Children Care (Form Lic 627, Form Lic 9166, Form Lic 700, Form Lic 995a, Form Lic 9212) Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CONSENT FOR EMERGENCY MEDICAL TREATMENT-
Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO
Pacific Beach Early Learning Center
_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME
PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
__________________________________________________ . THIS CARE MAY BE GIVEN UNDER
NAME
WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
HOME ADDRESS
HOME PHONE
WORK PHONE
(
)
(
)
LIC 627 (9/08) (CONFIDENTIAL)

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