Personal Rights Acknowledement

LIC 613A Personal Rights Acknowledgement

California DSS Child Care Center Personal Rights form.

URL

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

Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:

To be accorded dignity in personal relationships with staff and others.
To be provided safe, healthful, and comfortable accommodations and equipment.
To be free from corporal punishment, humiliation, intimidation, ridicule, coercion, threats, mental abuse, or punitive actions.
To be informed of complaint procedures and licensing agency contact information.
To freely attend religious services or activities of choice on a voluntary basis.
Not to be locked in any room, building, or facility premises.
Not to be placed in restraining devices except approved supportive restraints.

By signing below, you acknowledge receipt and understanding of these personal rights under California Code of Regulations, Title 22.

Facility Name(Required)

Facility Address(Required)

Child Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Title/Relationship to Child(Required)

Acknowledgement(Required)

I acknowledge that I have received and understand the California Personal Rights information.

Parent/Guardian Signature(Required)

Date(Required)