Identification & Emergency Information

LIC 700 Identification and Emergency Information

California DSS LIC 700 form.

Phone

This field is for validation purposes and should be left unchanged.

LIC 700 - Identification and Emergency Information

California Department of Social Services - Child Care Centers / Family Child Care Homes

Child Name(Required)

First Last

Child Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex(Required)

Male

Female

Birthdate(Required)

Father/Guardian Name

First Last

Father/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father/Guardian Home Telephone

Father/Guardian Business Telephone

Mother/Guardian Name

First Last

Mother/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother/Guardian Home Telephone

Mother/Guardian Business Telephone

Person Responsible For Child(Required)

First Last

Physician Name

Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Plan and Number

Dentist Name

Dentist Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Dentist Medical Plan and Number

Time Child Will Be Called For

If Physician Cannot Be Reached

Call Emergency Hospital

Other

Other Emergency Instructions

Persons Authorized to Take Child From Facility

Authorized Person #1 Name

Authorized Person #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorized Person #1 Telephone

Authorized Person #1 Relationship

Authorized Person #2 Name

Authorized Person #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorized Person #2 Telephone

Authorized Person #2 Relationship

Additional Persons Who May Be Called In An Emergency

Emergency Contact #1 Name

Emergency Contact #1 Home Telephone

Emergency Contact #1 Business Telephone

Emergency Contact #1 Relationship

Emergency Contact #2 Name

Emergency Contact #2 Home Telephone

Emergency Contact #2 Business Telephone

Emergency Contact #2 Relationship

Parent/Guardian Signature(Required)

Signature Date(Required)

Date of Admission

Identification & Emergency Information

LIC 700 Identification and Emergency Information

LIC 700 - Identification and Emergency Information

Persons Authorized to Take Child From Facility

Additional Persons Who May Be Called In An Emergency

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