Form CD-9606, (Rev. June 2008) STATEMENT OF PARENTAL ...

CALIFORNIA DEPARTMENT OF EDUCATION Child Development Division Form CD-9606, (Rev. June 2008)

STATEMENT OF PARENTAL INCAPACITY

NOTE: When applicable, this form is to be completed and used with form, CD-9600.

Please print or type information.

PART I ? To be completed by the authorized agency representative and the incapacitated parent.

By signing this form and for the purpose of verifying my incapacity to care for the family's children as it relates to the family's eligibility for

subsidized child care and development services, I authorize and request the health professional named in Part II to release the information

requested to the agency identified below. I further authorize the health professional to discuss this Statement of Incapacity with the agency

in order for the agency to verify, clarify, or complete it. I understand the health professional may also require that I complete his or her own

release form prior to providing the information requested below.

NAME OF PARENT/CARETAKER

SIGNATURE OF PARENT/CARETAKER

DATE

FIRST NAME AND AGE OF THE CHILD(REN) FOR WHOM FINANCIAL ASSISTANCE FOR CHILD CARE IS BEING REQUESTED:

1.

2.

3.

4.

AGENCY ADDRESS

AUTHORIZED AGENCY REPRESENTATIVE (Please print.) TELEPHONE NUMBER

CITY

(

)

ZIP CODE

PART II ? To be completed by the licensed health professional. For the family to be eligible to receive child care and development services under the category of incapacity, the California law requires verification, at least annually, of the physical or mental incapacity of the parent or caretaker that renders the person incapable of caring for or supervising the family's child(ren) without assistance. (See California Code of Regulations,Title 5, ?18088.) Your cooperation in completing and returning this form to the agency listed above within 15 days of receipt is requested.

PATIENT ___________________ HAS a physical condition or

Please indicate the time in a day and the days of the week, not to exceed 50 hours in a week, that the parent is unable to care for or supervise the child(ren).

Child care

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

a mental health condition

that prevents him or her from providing care or supervision for the child(ren) listed above for at least part of the day.

PROBABLY DATES OF INCAPACITY

From:

To:

Start Time:

am/

am/

pm

pm

am/

am/

am/

am/

am/

pm

pm

pm

pm

pm

End Time:

am/

am/

pm

pm

am/

am/

am/

am/

am/

pm

pm

pm

pm

pm

If the time of day cannot be easily identified in consultation with the patient, please identify the number of

hours and days of the week [M, T, W, T, F, S, S] that services are needed.

If the parent has a physical/medical condition, please identify the extent to which the parent is incapable of providing care and supervision.

Please sign and submit this form to the agency listed in Part I within 15 days of receipt of this form.

NAME OF LICENSED HEALTH PROFESSIONAL

LICENSE TYPE

SIGNATURE OF LICENSED HEALTH PROFESSIONAL

DATE

MEDICAL GROUP OR ORGANIZATION WITH WHICH THE PROFESSIONAL IS AFFILIATED, IF ANY

ADDRESS

CITY

LICENSE NUMBER

TELEPHONE NUMBER

(

)

STATE

ZIP CODE

CALIFORNIA DEPARTMENT OF EDUCATION Child Development Division Form CD-9606, (Revised: 02/04)

DECLARACI?N DE INCAPACIDAD

(PADRE, MADRE O CUIDADOR)

NOTA: Complete este formulario cuando corresponda y ?selo con el formulario, CD-9600.

Por favor, escriba la informaci?n con letra de imprenta o a m?quina.

PARTE I: Para ser completada por un representante autorizado de la agencia.

Instrucciones: Para que el ni?o/a (o los ni?os/as) a cargo del padre, madre o cuidador/a re?nan los requisitos necesarios para recibir

servicios de desarrollo infantil, el Departamento de Educaci?n de California exige una verificaci?n que indique que las necesidades

especiales m?dicas o psiqui?tricas del padre, madre o cuidador/a no pueden satisfacerse sin que se proporcionen servicios de desarrollo

infantil.

NOMBRE DEL PADRE, MADRE O CUIDADORES

FIRMA DEL PADRE, MADRE O CUIDADORES

El padre, madre o cuidador/a mencionado anteriormente nos ha autorizado para que nos comuniquemos con usted y realicemos dicha

verificaci?n. Su cooperaci?n al responder las preguntas

y devolver este formulario a la agencia que se menciona a continuaci?n dentro de un plazo de dos semanas permitir? que nuestra agencia

determine la elegibilidad.

AGENCIA

REPRESENTANTE AUTORIZADO DE LA AGENCIA

N?MERO DE TEL?FONO

(en letra de imprenta)

(

)

DOMICILIO

CIUDAD

C?DIGO POSTAL

PARTE II: Para ser completada por un profesional con licencia.

NATURALEZA DE LA INCAPACIDAD

FECHAS APROXIMADAS DE LA INCAPACIDAD

Desde

Hasta

?La naturaleza de la incapacidad le impide al padre, madre o cuidador/a cuidar al ni?o/a sin recibir ayuda durante al menos una parte del d?a?

S?

No

CANTIDAD DE HORAS POR D?A QUE EL NI?O DEBE SER

CUIDADO

?Necesita ser hospitalizado

en este momento?

Lun Mar Mi? Jue Vie S?b Dom

S?

No

COMENTARIOS (agregue otra hoja si es necesario): FIRMA DEL PROFESIONAL CON LICENCIA TIPO DE LICENCIA O CREDENCIAL DOMICILIO

FECHA CIUDAD

TEL?FONO

N?MERO DE LICENCIA O CREDENCIAL

ESTADO

C?DIGO POSTAL

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