Lic 700 Form PDF Details

The LIC 700 form provides identification and emergency information for child care centers or family child care homes. Using the LIC 700 form, a parent or legal guardian authorizes the facility to care for their child.

This article includes specifics of the LIC 700 form. You should study it before filling in the form.

QuestionAnswer
Form Name Lic 700 Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names lic 700 form no download needed, lic700, identification and emergency information lic 700, lic 700 form english

Form Preview Example

STATE OF CALIFORNIA

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

HEALTH AND HUMAN SERVICES AGENCY

COMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CHILD’S NAME

LAST

MIDDLE

FIRST

SEX

TELEPHONE

 

 

 

 

 

 

 

 

(

)

ADDRESS

NUMBER

STREET

 

CITY

STATE

ZIP

BIRTHDATE

 

 

 

 

 

 

 

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME

LAST

MIDDLE

 

FIRST

 

BUSINESS TELEPHONE

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

HOME ADDRESS

NUMBER

STREET

 

CITY

STATE

ZIP

HOME TELEPHONE

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME

LAST

MIDDLE

 

FIRST

 

BUSINESS TELEPHONE

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

HOME ADDRESS

NUMBER

STREET

 

CITY

STATE

ZIP

HOME TELEPHONE

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

PERSON RESPONSIBLE FOR CHILD

LAST NAME

 

MIDDLE

FIRST

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 CALLED FOR

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE

DATE

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

DATE OF ADMISSION

LIC 700 (8/08)(CONFIDENTIAL)

DATE LEFT

How to Edit LIC 700 Form Online for Free

We have applied the efforts of the best computer programmers to create the PDF editor you may want to apply. The application will let you fill in the lic700 document easily and don’t waste time. What you need to do is stick to the next easy-to-follow steps.

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Step 2: At the moment, you can change your lic700. Our multifunctional toolbar lets you insert, delete, customize, highlight, and also undertake other sorts of commands to the content material and areas within the file.

The next parts are what you are going to complete to have the prepared PDF file.

example of gaps in lic 700 form no download needed

The system will expect you to complete the DENTIST, ADDRESS, MEDICAL PLAN AND NUMBER, TELEPHONE, IF PHYSICIAN CANNOT BE REACHED, CALL EMERGENCY HOSPITAL, OTHER, EXPLAIN, NAMES OF PERSONS AUTHORIZED TO, NAME, RELATIONSHIP, TIME CHILD WILL BE CALLED FOR, SIGNATURE OF PARENTGUARDIAN OR, DATE, and DATE OF ADMISSION field.

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