CHILD CARE FACILITY ROSTER (RETAIN FOR 3 YEARS) CHILD …
STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
CHILD CARE FACILITY ROSTER (RETAIN FOR 3 YEARS) CHILD CARE CENTERS, INFANT CARE CENTERS, SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES
FACILITY NAME:
CHILD'S NAME/ BIRTHDATE
ADDRESS
PARENT/GUARDIAN NAME(S)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTE:
This roster must be kept in a central location at the facility, updated as needed and made available to the licensing agency upon request.
Health and Safety Code Section 1596.841 requires that each child care facility maintain a current roster of children who are provided care in the facility. The roster shall include the child's name, address, names and day phone numbers of the parent(s) or guardian(s) and name and phone number of the child's physician. This is an optional form that may be used for this purpose.
FACILITY LICENSE NUMBER:
DATE/UPDATE:
DAYTIME PHONE OF PARENT/GUARDIAN
PHYSICIAN NAME AND PHONE
DATE ENROLLED
DATE LEFT
LIC 9040 (10/05)
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