LIC700 Form

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME

MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

1.

2.

3.

4.

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

CALL EMERGENCY HOSPITALOTHER

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

1.

2.

3.

4.

5.

TIME CHILD WILL BE CALLED FOR

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

DATE OF ADMISSION

LIC 700 (8/08)(CONFIDENTIAL)

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