Form LIC700 "Identification and Emergency Information Child Care Centers/Family Child Care Homes" - California

What Is Form LIC700?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC700 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC700 "Identification and Emergency Information Child Care Centers/Family Child Care Homes" - California

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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
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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