Required 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:

Child’s Date of Birth (mm/dd/yyyy):

 

       

 

 

     

 

     

 

 

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: June 18, 2019

Technique Kids' Activity Center https://www2.techniquegym.com
Signature Certificate
Document name: Required Identification and Emergency Information Child Care Centers / Family Child Care Homes
Unique Document ID: 0dff91f4ce1348c31dc1cca915e95a4f17c52f4f
Timestamp Audit
April 8, 2019 5:24 pm PDTRequired Identification and Emergency Information Child Care Centers / Family Child Care Homes Uploaded by Kathy Olvera - info@techniquegym.com IP 192.163.242.93
April 8, 2019 5:33 pm PDTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
April 8, 2019 5:33 pm PDTTechnique Admin - admin@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
May 29, 2019 10:00 am PDT Document owner kathyolvera1@gmail.com has handed over this document to info@techniquegym.com 2019-05-29 10:00:12 - 192.163.242.93
May 29, 2019 10:00 am PDTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
May 29, 2019 10:00 am PDTTechnique Admin - admin@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
June 18, 2019 1:06 pm PDTKathy Olvera - info@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93
June 18, 2019 1:06 pm PDTTechnique Admin - admin@techniquegym.com added by Kathy Olvera - info@techniquegym.com as a CC'd Recipient Ip: 192.163.242.93