Form Lic 9150 - Parent Notification - Additional Children Care (Form Lic 627, Form Lic 9166, Form Lic 700, Form Lic 995a, Form Lic 9212) Page 4

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STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
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
Pacific Beach Early Learning Center
(
)
ADDRESS
NUMBER
STREET
CITY
STATE
ZIP
BIRTHDATE
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME
LAST
MIDDLE
FIRST
BUSINESS TELEPHONE
(
)
HOME ADDRESS
NUMBER
STREET
CITY
STATE
ZIP
HOME TELEPHONE
(
)
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME
LAST
MIDDLE
FIRST
BUSINESS TELEPHONE
(
)
HOME ADDRESS
NUMBER
STREET
CITY
STATE
ZIP
HOME TELEPHONE
(
)
PERSON RESPONSIBLE FOR CHILD
LAST NAME
MIDDLE
FIRST
HOME TELEPHONE
BUSINESS TELEPHONE
(
)
(
)
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: ____________________________________________________________________________________________________________________
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 CALLED FOR
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE
DATE
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION
DATE LEFT
LIC 700 (8/08)(CONFIDENTIAL)

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