Transcription of IDENTIFICATION AND EMERGENCY INFORMATION …
1 PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCYNAMES 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 LICENSEESTATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISIONIDENTIFICATION AND EMERGENCY INFORMATIONCHILD CARE CENTERS/FAMILY CHILD CARE HOMESTo Be Completed by Parent or Authorized RepresentativeCHILD S NAMELASTMIDDLEFIRSTADDRESSNUMBERSTREETCI TYSTATEZIPFATHER S/GUARDIAN S/FATHER S DOMESTIC PARTNER S NAME LASTMIDDLEFIRSTHOME ADDRESSNUMBERSTREETCITYSTATEZIPMOTHER S/GUARDIAN
2 S/MOTHER S DOMESTIC PARTNER S NAME LASTMIDDLEFIRSTHOME ADDRESSNUMBERSTREETCITYSTATEZIPPERSON RESPONSIBLE FOR CHILDLAST NAMEMIDDLEFIRSTPHYSICIANADDRESSMEDICAL PLAN AND NUMBERDENTISTADDRESSMEDICAL PLAN AND NUMBERTIME CHILD WILL BE CALLED FORSIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVEDATE OF ADMISSIONIF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? CALL EMERGENCY HOSPITAL OTHEREXPLAIN: _____NAMENAMEADDRESSTELEPHONERELATIONSHI PRELATIONSHIPSEXHOME TELEPHONE( )TELEPHONE( )TELEPHONE( )TELEPHONE( )DATEDATE LEFTBIRTHDATEBUSINESS TELEPHONE( )BUSINESS TELEPHONE( )BUSINESS TELEPHONE( )HOME TELEPHONE( )HOME TELEPHONE( )ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCYLIC 700 (8/08)(CONFIDENTIAL)
