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)
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- authorization agreement b request status
- uniform and insignia wear and appearance of army uniforms
- system authorization access request saar
- child care facility roster retain for 3 years child
- name montreal cognitive assessment moca
- the constitution of the united states
- oswestry low back disability questionnaire
- a rose for emily by william faulkner 1930 i
- fl 150 income and expense declaration
- leave request form authorization united states navy