STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

AFFIDAVIT REGARDING LIABILITY INSURANCE
FOR FAMILY CHILD CARE HOME

SECTION A:

I/We, the parent(s)/guardian(s) of ,

(Child's Name)

acknowledge that ,

(Licensee'sName)

the licensee of ,

(Name of Family Child Care Home)

has informed me/us that this facility does not carry liability insurance or a bond in accordance with standards established by

Family Child Care statute.

SECTION B: To be completed only if licensee does not own premises or the licensee is a member of a condominium

or Homeowner's Association.

I/We, the parent(s)/guardian(s) of ,

(Child's Name)

acknowledge that ,

(Licensee's Name)

the licensee of .

(Name of Family Child Care Home)

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