LIC 700 Form PDF Details

State of California Health and Human Services Agency, California Department of Social Services (CONFIDENTIAL).

Child: Child's name, sex, telephone, address and birthdate

Persons to call: Parent or authorized representative, person responsible for child, additional persons who may be called in an emergency

Medical: Physician and dentist, address, medical plan and number, telephone

If physician cannot be reached: Call emergency hospital, or other, explain

Persons authorized to take child: Child will not be allowed to leave with any other person without written authorization from the parent or authorized representative

Facility: To be completed by the facility director, administrator or family child care homes licensee: date of admission, last date of enrollment

Question	Answer
Form Name	LIC 700 Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	81
Avg. time to fill out	14 min
Other names	LIC 700, LIC700, LIC 700 form, LIC 700 form pdf
Edition	10/19

How to Fill Out Form LIC 700

Form LIC 700 at a glance

What it is: LIC 700 is the Identification and Emergency Information form for child care centers and family child care homes.

Who signs: The parent/guardian or authorized representative signs and dates the form.

To be completed by the parent or authorized representative.

A filled-in Form LIC 700 example: a mother enrolls her son

Form LIC 700 example filled out, example: a mother enrolls her son — Maria Sample fills out Form LIC 700 for her son Leo. If his physician cannot be reached, she ticks Call Emergency Hospital, so Other stays empty. The picture shows page 1 only, and none of its entries is real.

How to fill out Form LIC 700, box by box

Child's name, address and birthdate

Enter the child's name (last, middle, first), sex, telephone, address (number, street, city, state, zip) and birthdate.

Parent / Authorized Representative

Under each Parent / Authorized Representative, enter the name (last, middle, first), business telephone, home address (number, street, city, state, zip) and home telephone.

Person Responsible for Child

Under Person Responsible for Child, enter last, middle and first, then home telephone and business telephone.

Additional Persons Who May Be Called in an Emergency

Under Additional Persons Who May Be Called in an Emergency, enter the name, address, telephone and relationship.

Physician or Dentist to Be Called in an Emergency

Under Physician or Dentist to Be Called in an Emergency, enter the physician and the dentist, each with address, medical plan and number, and telephone.

If Physician Cannot Be Reached, What Action Should Be Taken?

If the physician cannot be reached, mark the action that should be taken: Call Emergency Hospital, or Other and explain.

Names of Persons Authorized to Take Child From the Facility

Names of persons authorized to take the child from the facility: the child will not be allowed to leave with any other person without written authorization from the parent or authorized representative.

Enter the name and relationship.

Enter the time the child will be picked up.

Signature of Parent/Guardian or Authorized Representative

The parent/guardian or authorized representative signs and dates the form.

To Be Completed by Facility Director/Administrator/Family Child Care Homes Licensee

The facility director/administrator/family child care homes licensee completes the Date of Admission and the Last Date of Enrollment.

Sources

[1] Form LIC 700 (10/19), Identification and Emergency Information, Child Care Centers/Family Child Care Homes, California Department of Social Services (the Official source link on this page).

LIC 700 Form: Identification and Emergency Information