Form Lic 613A at a glance
What it is: California Department of Social Services, Personal Rights, Child Care Centers.
Who signs: Signature of the representative/parent/guardian; title of the representative/parent/guardian; date.
A filled-in Form Lic 613A example: a parent signs for a child's admission
How to fill out Form Lic 613A, box by box
The licensing agency to contact about complaints
The representative/parent/guardian has the right to be informed of the appropriate licensing agency to contact regarding complaints, which is: Name, Address, City, Zip Code, Area Code/Telephone Number.
The facility and the child
Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to:
Print the name of the facility and the address of the facility.
Print the name of the child.
The title of the representative and the date
Signature of the representative/parent/guardian; title of the representative/parent/guardian; date.
More rules for Form Lic 613A
See Title 22, Section 101223 of the California Code of Regulations for personal rights applicable to Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include the following:
(1) To be accorded dignity in their personal relationships with staff and other persons.
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet their needs.
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
(4) To be informed, and to have their authorized representative informed, by the licensee of the law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.
(5) To be free to attend religious services or activities of their choice. Attendance at religious services, either in or outside the facility, shall be voluntary. In Child Care Centers, decisions concerning attendance at religious services shall be made by the child's authorized representative. To the extent that the child's authorized representative has agreed to the child's compulsory attendance at religious services and activities as a condition of admission in the admission agreement, a Child Care Center may require a child's attendance at such religious services and activities.
(6) Not to be locked in any room, building, or facility premises by day or night.
(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.
Detach here. To: Parent/Guardian/Child or Authorized Representative; place in child's file.
Sources
[1] Form Lic 613A (12/25), Personal Rights, Child Care Centers, California Department of Social Services (the Official source link on this page).