LIC 700 Emergency Information

State of California – Health and Human Services Agency
California Department of Social Services
LIC 700 (10/19) (CONFIDENTIAL)

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CHILD’S NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

TELEPHONE:

SEX:

BIRTHDATE:

PARENT / AUTHORIZED REPRESENTATIVE

NAME:

HOME ADDRESS:

STREET:

CITY:

STATE:

ZIP:

HOME TELEPHONE:

BUSINESS TELEPHONE:

PARENT / AUTHORIZED REPRESENTATIVE

NAME:

HOME ADDRESS

STREET:

CITY:

STATE:

ZIP:

HOME TELEPHONE:

BUSINESS TELEPHONE:

PERSON RESPONSIBLE FOR CHILD

NAME:

HOME TELEPHONE:

BUSINESS TELEPHONE:

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME	ADDRESS	TELEPHONE	RELATIONSHIP

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

PHYSICIAN:

ADDRESS:

MEDICAL PLAN AND NUMBER:

TELEPHONE:

DENTIST:

ADDRESS:

MEDICAL PLAN AND NUMBER:

TELEPHONE:

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

	CALL EMERGENCY HOSPITAL
	OTHER	EXPLAIN:

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)

NAME	RELATIONSHIP

TIME CHILD WILL BE PICKED UP:

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

DATE OF ADMISSION:

LAST DATE OF ENROLLMENT:

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Your legal name

Your email address

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Signed by Kathy Olvera
Signed On: January 27, 2021

Timestamp

Audit

January 9, 2021 7:25 pm PST

LIC 700 Emergency Information Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93