Technique Kids' Activity Center

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

     

Gender:

 

       

 

 

     

 

     

 

 

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

  

       

    

 

    

       

    

 

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

    

       

    

 

    

       

    

 

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)

    

    

    

    

    

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.

 

LIC 627 (9/08) (CONFIDENTIAL)

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Signed by Kathy Olvera
Signed On: November 17, 2018

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: a6a1bef8938d8617c5bfa28b49d3a897b41a70af
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
April 27, 2018 3:13 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 27, 2018 3:13 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 27, 2018 3:23 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 27, 2018 3:23 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 27, 2018 3:32 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 27, 2018 3:32 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 27, 2018 3:34 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 27, 2018 3:34 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - tanya.durant@gmail.com as a CC'd Recipient Ip: 192.163.242.93
May 29, 2018 1:43 pm PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
May 29, 2018 1:43 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
November 1, 2018 8:45 pm PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
November 1, 2018 8:45 pm PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
November 17, 2018 11:22 am PSTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
November 17, 2018 11:22 am PSTKathy Olvera - techniquea2camps@gmail.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
November 17, 2018 11:22 am PSTKathy Olvera - kathyolvera1@gmail.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
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https://www2.techniquegym.com/
Audit Trail Serial# 3a6ec0463a1698326038d2a218ee95dc