STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES
To Be Completed by Parent or Authorized Representative
CHILD’S NAME LAST
MIDDLE
FIRST
TELEPHONE
( )
ADDRESS NUMBER STREET
CITY
STATE
BIRTHDATE
FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST
MIDDLE
FIRST
BUSINESS TELEPHONE
( )
HOME ADDRESS NUMBER STREET
CITY
STATE
HOME TELEPHONE
( )
MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST
MIDDLE
FIRST
BUSINESS TELEPHONE
( )
HOME ADDRESS NUMBER STREET
CITY
STATE
HOME TELEPHONE
( )
PERSON RESPONSIBLE FOR CHILD LAST NAME
MIDDLE
FIRST
HOME TELEPHONE
( )
BUSINESS TELEPHONE
( )
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY
NAME
ADDRESS
TELEPHONE
RELATIONSHIP
PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN
ADDRESS
MEDICAL
PLAN
AND
NUMBER
TELEPHONE
( )
DENTIST
ADDRESS
MEDICAL
PLAN
AND
NUMBER
TELEPHONE
( )
IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?
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