Form LIC996c "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)" - California

What Is Form LIC996c?

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 August 1, 2008;
  • 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 LIC996c 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 LIC996c "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)" - California

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REINSTATEMENT)
The law requires the licensee to notify you that the person whose name appears below is now allowed to
be present in the Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
After either a careful and thorough review by the Department, or an Administrative Law Judge, this person
may now be in the Family Child Care Home when children are in care.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility:
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
A C K N O W L E D G M E N T O F
A D D E N D U M T O N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E I N S TAT E M E N T )
This will acknowledge that I, the parent/authorized representative of _______________________________,
have received a copy of the “ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS (REGARDING
REINSTATEMENT” from the licensee or designated representative. (Parent/Authorized Representative
signature is required) .
______________________________________________
_______________________
Signature of Parent/Authorized Representative
Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995C (8/08)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FAMILY CHILD CARE HOME
ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS
(REGARDING REINSTATEMENT)
The law requires the licensee to notify you that the person whose name appears below is now allowed to
be present in the Family Child Care Home.
Name:
_____________________________________________________
Effective Date:
_____________________________________________________
After either a careful and thorough review by the Department, or an Administrative Law Judge, this person
may now be in the Family Child Care Home when children are in care.
Licensing Office Name:
_____________________________________________________
Licensing Office Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
Name And Address of This Facility:
Facility Name:
_____________________________________________________
Facility Address:
_____________________________________________________
City/State/Zip:
_____________________________________________________
A C K N O W L E D G M E N T O F
A D D E N D U M T O N O T I F I C AT I O N O F PA R E N T S ’ R I G H T S
( R E G A R D I N G R E I N S TAT E M E N T )
This will acknowledge that I, the parent/authorized representative of _______________________________,
have received a copy of the “ADDENDUM TO NOTIFICATION OF PARENTS’ RIGHTS (REGARDING
REINSTATEMENT” from the licensee or designated representative. (Parent/Authorized Representative
signature is required) .
______________________________________________
_______________________
Signature of Parent/Authorized Representative
Date
NOTE: This form with the original signature of the parent/authorized representative must be kept in
the child’s file. A copy of this form must be given to the parent/authorized representative.
LIC 995C (8/08)