Form LIC613A "Personal Rights - Child Care Centers" - California

What Is LIC 613A?

Form LIC 613A, Personal Rights - Child Care Centers, is a document signed by a child's parent, guardian, or representative in order to acknowledge that a child's personal rights are observed and respected while the child is receiving services from a child care center. Once the form is signed, the bottom of the document is detached and placed in the child's file, while the representative keeps the upper part of the form.

This form was released by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS), in August 2008. Download a fillable LIC 613A Form through the link below.

Form LIC 613A (SP), Derechos Personales - Guarderías Infantiles, a LIC 613A Spanish version, can also be found on our website.

The LIC personal rights form specifies the following rights of the child:

  1. Dignity with the personal relationship of the child care center staff and other individuals;
  2. Safety, comfortable and healthy accommodations, proper environment and equipment;
  3. Freedom from corporal and unusual punishment, pain, mental abuse, and other actions punitive by nature. The form emphasizes freedom from interference with daily functions and grants access to shelter, medication, and clothing;
  4. Right of the child and the child's representative to receive information about the provisions of law regarding complaints. The document states the name, address, and phone number of the licensing agency to contact in this situation;
  5. Freedom to attend religious activities and services and receive visits from a spiritual advisor;
  6. Right not to be locked in any room of the facility or be placed in restraining devices.
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Download Form LIC613A "Personal Rights - Child Care Centers" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a)
Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
not limited to, the following:
(1)
To be accorded dignity in his/her personal relationships with staff and other persons.
(2)
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her
needs.
(3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily
living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to
physical functioning.
(4)
To be informed, and to have his/her authorized representative, if any, informed by the licensee of the
provisions of law regarding complaints including, but not limited to, the address and telephone number of the
complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5)
To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor
of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely
voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from
spiritual advisors shall be made by the parent(s), or guardian(s) of the child.
(6)
Not to be locked in any room, building, or facility premises by day or night.
(7)
Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
NAME
ADDRESS
CITY
ZIP CODE
AREA CODE/TELEPHONE NUMBER
DETACH HERE
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:
PLACE IN CHILD'S FILE
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the
California Code of Regulations, Title 22, at the time of admission to:
(PRINT THE ADDRESS OF THE FACILITY)
(PRINT THE NAME OF THE FACILITY)
(PRINT THE NAME OF THE CHILD)
(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(DATE)
LIC 613A (8/08)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL RIGHTS
Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.
(a)
Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
not limited to, the following:
(1)
To be accorded dignity in his/her personal relationships with staff and other persons.
(2)
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her
needs.
(3)
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,
threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily
living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to
physical functioning.
(4)
To be informed, and to have his/her authorized representative, if any, informed by the licensee of the
provisions of law regarding complaints including, but not limited to, the address and telephone number of the
complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5)
To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor
of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely
voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from
spiritual advisors shall be made by the parent(s), or guardian(s) of the child.
(6)
Not to be locked in any room, building, or facility premises by day or night.
(7)
Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing
agency.
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE
LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
NAME
ADDRESS
CITY
ZIP CODE
AREA CODE/TELEPHONE NUMBER
DETACH HERE
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:
PLACE IN CHILD'S FILE
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:
ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in the
California Code of Regulations, Title 22, at the time of admission to:
(PRINT THE ADDRESS OF THE FACILITY)
(PRINT THE NAME OF THE FACILITY)
(PRINT THE NAME OF THE CHILD)
(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN)
(DATE)
LIC 613A (8/08)