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INFORMATION
ANDEMERGENCY
IDEilTIFICATION
CHILDCAHEHOMES
CHILDCARECENTERSIFAMILY
To Fc Complctrd by Par$t or AuthorlzsdRcprarntatlvc
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HOMEAOOHESS NUMBEH env

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PENSONFIEBPOI{B'BL€FOHEfiILO I.ASINAME MIODLE

ADD]TIONAL
PERSOI{8WHOMAYBE CALLEDIN AN EMEFqE'IICY
ADDRESS i
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TETEPHONE REI-ATIONSHIP
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NAMESOFPERSOilS
AUTHORtrEDTOTAKE
CHILDFROMTHE
FACILITY
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STATEOF CAUFffi'I!A--]JEALIH ANDHUu^N SER1IICES
AGEXAY CAUFONilA D€FAFfME}ITOF SOCIALSERVrcES
comruMTY GAFELIC€'{SI{G OfvlsDi{

FAMILY CHILD CARE HOME

NOTIFICAT|oN OF PARENTS' RIGHTS
PARENTS'RIGHTS

As a Parent/AuthorizedRepresentative,you have the right to:

1. Enterand inspectthe familychild care homewithoutadvancenoticewheneverchildrenare in care.

2. File a complaintagainstthe licenseewith the licensingoffice and revieurthe licensee'spublicfile

keptby the licensingoffice.

3. Revieq at the familychild care home,reportsof licensingvisits and substantiatedcomplaints

againstthe licenseemadeduringthe last three years.
4- Complainto the licensingotficeand inspectthe familychild care home withoutdiscriminationor
retaliationagainstyou or your child.
5. Be notifiedand receive,from the licensee,a written notice that lists the name of any person not
allowed in the family child care home while children are present. (NOTE: Thts notlc€ ls only
rqultd when the Etepartment has,ln wrttlng, exdudd someone fiom the tamlly chlld ere
home on or aft* January 1, Znl).

6, Requestin writing that a parent not be allowedto visit your child or take your child from the family
child care home,providedyou haveshowna certifiedcopy of a court order.
7. Receivefrom the licenseethe name,addressand telephonenumberof the local lforensing
office.

LicensingOfficeName:
LicensingOtficeAddress:
LicensingOfficeTelephone#:
8. Be informedby the licensee,upon request,of the name and type of associationto the familychild
care home for any adult who has been granteda criminalrecordexempt'ron, and that the name of
the person may also be obtained by contactingthe local licensingoffice.

9. Receive,from the licensee,the CaregiverBackgroundCheckProcessform.

10. Be informed,by the licensee,that the hcility has or does not have liabilityinsurance(or a bond) that
coversinjuryto clientsdue to the negligenceof the licenseeor employeesof the facility.
NOTE: CALIFOBNASTATELAw PROVIDESTHATTHE
LICENSEEnAY DENYACCESSTOTHEFAWLYCHILD
CABE HOME TO A PANENTIAUTHORIZEDNEPNESENTATIVEIF THE BEHAVIOE OF THE
PABENTIAUTHOEIZED
BEPRESENTATIVE
POSESA BISK7A CH'LDRENIN CAEE.

For he fuParUnantof Justie "Bqis|arrcd &x arcnAefAabh*, go to www.neganslaw-aa.gov

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ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS
(ParenAAuthorizd Beprwntative Signaturc@uircd)

l, the parent/authorized
represenAtive
d harnereeived a mgf of the fAIIIILY
CHITD HOMENOTIFICAT]OilI
OARE OFMRENIS'RIGHTS",
TECAREGIVER
BACKGroJNDGHECKFrcGESS
and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the

Signaturo (Parent/AuthorizedRepresantalive)

NOTE: ThE Acknowledgement must be Reptin chtH's file aN a copy of the Notification given to the
parenVauthorized rcp tesc;rrtafi
ve.

For the Deprtment ot Justice "Regisbred *x Ottendef'dahbase, go to www.meganslaw.ce.gov

LIC 9954 (6108)
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FOHEMERGENCY
GOf.ISET.IT MEDICALTFEATTSEN?
Child CareCentenEOr FamilyChild CareHomes

I HEHEBYGIVECONSENTTO
REPHESEiITATIVE,
ASTHEPAFEHTOHAI..'THOR|ZED
KIDDIECASTLE CHILDCARE MEDICALORDE$TALCAHE
TOOBTAINALL EMEHGENCY

PnESCHTBED
BYA DULYUCENSED (M.D.)OSTEOPATT{
PHYSTCTAN (DO.)ORDENTTST(D,D.S.)
FOH

, THISCAFEMAYBE GIVENUNDER

CONDMONSAAENEOESSAHY
WHATEVER TO FRESERVE
TFIELIFE,LIMBOHWELLBEINGOFTHECHILD

NAMEDABO/E.

CHITDFIASTI{EFOLLOWING ALLERdIES:
MEOGATON

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