Identification and Emergency Information Child Care Centers / Family Child Care Homes



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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

LIC 627 (9/08) (CONFIDENTIAL)

 

IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative


Child’s Last Name:    

Child’s Middle Name:   

Child’s First Name:

Gender

Child’s Date of Birth (mm/dd/yyyy): 

 

Child’s Address Line 1:

Child’s Address Line 2 (Optional):

City:   State:   Zip:  

Child’s Primary Phone #:  

 

Father’s/Guardian’s/Father’s Domestic Partner’s Name (First, Last):

Father’s/Guardian’s/Father’s Domestic Partner’s Address Line 1:

Father’s/Guardian’s/Father’s Domestic Partner’s Address Line 2 (Optional):

City:    State:    Zip:

Father’s/Guardian’s/Father’s Domestic Partner’s Primary Phone #:

Father’s/Guardian’s/Father’s Domestic Partner’s Business Phone # (Optional):

 

Mother’s/Guardian’s/Mothers Domestic Partner’s Name (First, Last):

Mother’s/Guardian’s/Mothers Domestic Partner’s Address Line 1:

Mother’s/Guardian’s/Mothers Domestic Partner’s Address Line 2 (Optional):

City:   State:   Zip:

Mother’s/Guardian’s/Mothers Domestic Partner’s Primary Phone #:

Mother’s/Guardian’s/Mothers Domestic Partner’s Business Phone # (Optional):

 

Person Responsible for Child’s Name (First, Last):

Person Responsible for Child’s Primary Phone #:

Person Responsible for Child’s Business Phone # (Optional):

 

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY


Emergency Contact 1’s First Name:   
Emergency Contact 1’s Last Name:

Emergency Contact 1’s Address Line 1 (Optional):
Emergency Contact 1’s Address Line 2 (Optional):
City:    State:    Zip:  

Emergency Contact 1’s Phone #:  

Emergency Contact 1’s Relationship to Child:  

 

Emergency Contact 2’s First Name:   
Emergency Contact 2’s Last Name:  

Emergency Contact 2’s Address Line 1 (Optional):
Emergency Contact 2’s Address Line 2 (Optional):
City:    State:    Zip:  

Emergency Contact 2’s Phone #:  

Emergency Contact 2’s Relationship to Child:  

 

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY


Physician’s First Name:  
Physician’s Last Name:  

Physician’s Address Line 1:
Physician’s Address Line 2 (Optional):
City:    State:    Zip:  

Physician’s Phone #:  

Medical Plan & Number:  

 

Dentist’s First Name:  
Dentist’s Last Name:   

Dentist’s Address Line 1:
Dentist’s Address Line 2 (Optional):
City:    State:   Zip:   

Dentist’s Phone #:  

Medical Plan & Number:  

 

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)


Authorized Pick Up Person 1 (Optional):  
Relationship to Child (Optional):  

Authorized Pick Up Person 2 (Optional):   
Relationship to Child (Optional):  

Authorized Pick Up Person 3 (Optional):   
Relationship to Child (Optional):  

Authorized Pick Up Person 4 (Optional):  
Relationship to Child (Optional):  

Authorized Pick Up Person 5 (Optional):   
Relationship to Child (Optional):  



TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

Date of Admission: ______________________    Date Left: _____________________________



 

CONSENT FOR EMERGENCY MEDICAL TREATMENT

Child Care Centers Or Family Child Care Homes


AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO Technique Adventure and Activity Camp TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR . THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.


Child has the following medication allergies:

 


LIC 627 (9/08) (CONFIDENTIAL)

Leave this empty:

Signed by Kathy Olvera
Signed On: November 4, 2019

Technique Kids' Activity Center https://www2.techniquegym.com
Signature Certificate
Document name: Identification and Emergency Information Child Care Centers / Family Child Care Homes
Unique Document ID: 2087dd90c13b40420376c7bf3268806d30bc9276
Timestamp Audit
April 26, 2018 1:28 pm PSTIdentification and Emergency Information Child Care Centers / Family Child Care Homes Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93
April 26, 2018 5:10 pm PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
April 26, 2018 5:10 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
April 26, 2018 5:12 pm PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
April 26, 2018 5:12 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
April 26, 2018 10:02 pm PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
April 26, 2018 10:02 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
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May 29, 2019 10:01 am PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
May 29, 2019 10:01 am PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
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