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:

 

Leave this empty:

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Signed by Kathy Olvera
Signed On: January 27, 2021

Signature Certificate
Document name: LIC 700 Emergency Information
lock iconUnique Document ID: 7a5f983ff9370c45099ae3113be9f21bb6e116cb
Timestamp Audit
January 9, 2021 7:25 pm PSTLIC 700 Emergency Information Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93