STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CURRENT CHILDREN IN YOUR HOME
APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE
Please list the name, date of birth, sex and relationship of each child living in your home. This form is intended for agency
use only and is relevant to the Application for a Family Child Care Home License, LIC 279.
The information contained in this form is not public. This form will be filed in the confidential section of the facility file.
CHILD’S FULL NAME
DATE OF BIRTH
SEX
RELATIONSHIP
LIC 279B (10/05) PERSONAL/CONFIDENTIAL
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CURRENT CHILDREN IN YOUR HOME
APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE
Please list the name, date of birth, sex and relationship of each child living in your home. This form is intended for agency
use only and is relevant to the Application for a Family Child Care Home License, LIC 279.
The information contained in this form is not public. This form will be filed in the confidential section of the facility file.
CHILD’S FULL NAME
DATE OF BIRTH
SEX
RELATIONSHIP
LIC 279B (10/05) PERSONAL/CONFIDENTIAL
