Common use of Child Care Centers Clause in Contracts

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757755M75etMroeptorolitpaonlitDarnivDe,r.S, Suiuteite111100 CITY San Diego SanSDainegDoiego, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((661199)) 776677-0000000 -22230000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITYXXXXXXXX) Xxxxxxxxx Xxxx Family YMCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757357M37etMroapionliStatn., DSruivitee,7S0u0ite 110 CITY San Diego SanRDivieegrsoide, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((691591) 776872-0000000 -24200 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITYXXXXXXXX) Xxxxxxxxx Xxxx Family YMCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: 0000 Xxxx Xx., Xxxxx 000, Xxxxxxxxx, XX 00000 (000) 000-0000 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. 000 Xxxxx 000 Xxxxxx Xxxxxx, Ste: 300 CITY San Diego Jose, CA ZIP CODE 92108 95113 AREA CODE/TELEPHONE NUMBER (000) 000-0000000 0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) World of Discovery Preschool (PRINT THE ADDRESS OF THE FACILITY) 00000 Xxxxxx Xxxxxxxx Xxxxx, Xxxxxxxx, XX (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Community Care Licensing 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: California Department of Social Services NAME Community Care Licensing Division ADDRESS 0000 Xxxxxxxxxxxx Xx. X Xxxxx Xxxxxx, Xxxxx 000 CITY San Diego XXXX Xxx Xxxx ZIP CODE 92108 95131 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) XXXXXXX SCHOOL (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: California Department of Social Services - CCL

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) San Diego Hebrew Day Preschool 0000 Xxxxx Xxxxx Xxx Xxxxx XX 00000 As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 0xx Xxxxxx Xxxxx 000 CITY San Diego Xxxx ZIP CODE 92108 95131 AREA CODE/TELEPHONE NUMBER 000(000)000-0000000 0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) A Place to Grow Preschool (PRINT THE ADDRESS OF THE FACILITY) 0000 Xxxxxxx Xx Bldg 2 Rooms 4&5 San Jose CA (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the family child care center home without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the family child care centerhome, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the family child care center home without discrimination or retaliation against you or your child. 5. Be notified and 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: This notice is only required when the Department has, in writing, excluded someone from the family child care home on or after January 1, 2001). 6. Request in writing that a parent not be allowed to visit your child or take your child from the family child care home, provided you have shown a certified copy of a court order. 7. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Community Care Licensing 0000 X. 0xx Xxxxxx Xxxxx 000, Xxx Xxxx Xx 00000 (408)324-2148 8. Be informed by the licensee, upon request, of the name and type of association to the family child care home for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 9. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Community Care Licensing Attn: Child Care Duty Officer 000 Xxxx Xxxxxx Xxxxx #A230 Rohnert Park, CA 94928 707.588.5026 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Little Lambs Preschool (PRINT THE ADDRESS OF THE FACILITY) 0000 Xxxxxxxxxx Xxxxxx Xxxxxxxxxx (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Community Care Licensing | Attn: Child Care Duty Officer 000 Xxxx Xxxxxx Xxxxx #X000 | Xxxxxxx Xxxx, XX 00000 707.588.5026 _________________________________________________ _________________________________________________ _________________________________________________ 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Palmdale Regional Child Care Licensing Office ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER Palmdale 000-0000000 000-0000 ZIP CODE 93550 00000 Xxxxx Xxxxxx Xxxxx, Xxx 000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Wanna Play Playcare (PRINT THE NAME OF THE CHILD) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) 00000 Xxxxxxx Xxxxxx Xxxx, Xxxxx Xxxxxxx, XX 00000 (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS NUMBER STREET CITY STATE ZIP BIRTHDATE FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS NUMBER STREET CITY STATE ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? ■ CALL EMERGENCY HOSPITAL ■ OTHER EXPLAIN: NAME RELATIONSHIP TIME CHILD WILL BE CALLED FOR SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE DATE OF ADMISSION DATE LEFT LIC 700 (8/08)(CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (CHILD’S PRE-ADMISSION HEALTH EVALUATION) (NAME OF CHILD) (BIRTH DATE) (NAME OF CHILD CARE CENTER/SCHOOL) a.m./p.m. to a.m./p.m. , days a Parentweek. Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Authorized RepresentativeSpeech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ (DIPHTHERIA, you TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS DT/Td AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / (REQUIRED FOR CHILD CARE ONLY) HIB MENINGITIS (HAEMOPHILUS B) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) ■ Risk factors not present; TB skin test not required. ■ Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present. ■ ■ I have have not reviewed the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee above information with the licensing office and review the licenseeparent/guardian. Physician: Date of Physical Exam: Address: Date This Form Completed: Telephone: Signature ■ Physician’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.Assistant ■ Nurse Practitioner LIC 701 (8/08) (Confidential) PAGE 1 OF 2

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx XxXxxxxxxxx Xxx. Xxxxx #000 CITY San Diego Goleta ZIP CODE 92108 93117 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC UC 613A (8/08) STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757755M75etMroeptorolitpaonlitDarnivDe,r.S, Suiuteite111100 CITY San Diego SanSDainegDoiego, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((661199)) 776677-0000000 -22230000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITYXXXXXXXX) Xxxxxxxxx Xxxx Family YMCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: (000) 000-0000 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757755M75etMroeptorolitpaonlitDarnivDe,r.S, Suiuteite111100 CITY San Diego SanSDainegDoiego, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((661199)) 776677-0000000 -22230000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Xxxxxxxxx Xxxx Family YMCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Community Care Licensing 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: California Department of Social Services NAME Community Care Licensing Division ADDRESS 0000 Xxxxxxxxxxxx Xx. X Xxxxx Xxxxxx, Xxxxx 000 CITY San Diego XXXX Xxx Xxxx ZIP CODE 92108 95131 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) XXXXXXX SCHOOL (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing Child Care Division ADDRESS 0000 Xxxxxxxxxxxx Xx. 000 Xxx Xxxx Xxxxx Xxxxx 000 CITY San Diego XXXX Xxxxxx ZIP CODE 92108 92668 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) St. John's Episcopal School Early Childhood Ctr 00000 Xxx Xxx Xxxx, XXX, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized RepresentativeAS THE PARENT OR AUTHORIZED REPRESENTATIVE, you have the right toI HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: Hospital used by family: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) Effective Date: School Year: Child: Grade: School: 1. Enter and inspect the child care center without advance notice whenever children are in care.Date of last tetanus shot Allergic to Parent’s phone number: Cell Number Address 2. File a complaint against My child is in good physical condition. Should any illness or accident occur on the licensee with trip, I will not hold liable Xxxxxxxx Baptist Church & Day School, its officers or leaders for medical aid rendered and will reimburse same for medical or other expenses incurred in the licensing office and review the licensee’s public file kept by the licensing officecare of my child. 3. Review, at the My child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three yearsmay receive necessary first aid. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xxxx Xx. Xxxxx , Xxx 000 CITY San Diego Riverside ZIP CODE 92108 92501 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Xxxxxxxx Baptist Day School (PRINT THE ADDRESS OF THE FACILITY) 28355 Base Line, Highland, CA 92346 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO Xxxxxxxx Baptist Day School TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: Hospital used by family: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) Child’s Name: Birth Date: Age: Parent’s Name: Phone #: Drop Off Time: Pick Up Time: Instructions from child’s pediatrician relating to special diet or feeding: List of any known allergies: Breast milk or brand of formula: Brand of formula: 6:00 a.m. 1:00 p.m. 7:00 a.m. 2:00 p.m. 8:00 a.m. 3:00 p.m. 9:00 a.m. 4:00 p.m. 10:00 a.m. 5:00 p.m. 11:00 a.m. 6:00 p.m. 12:00 p.m. 7:00 p.m. Plan for introducing solid and/or new foods: List of food child likes: Food Consistency: List of food child does not like: Plan for introducing cup/Authorized Representativeutensils at snack and mealtime: Diapering: Type: Number per day: Skin preparations: ointments, you have the right to: 1powder etc.: Plan for introducing “toilet training”: Xxxxx’s Sleeping Plan – What are your child’s sleeping habits and usual environments? Is your child able to roll over on their own? List any additional instructions or special need to provide quality care for your child: Director’s Signature: Date: Parent’s Signature: Date: *Next Conference Date: *Conference Date will be updated if there are any changes to this plan. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept “Recommendations for Infant Feeding Practices” by the licensing officeDepartment of Human Services Birth-12 months: Breast milk, iron fortified formula or evaporated milk formula At 4-6 months: Infant cereal (dry type) At 5-7 months: Vegetables, fruits and their juices At 6-8 months: Protein foods (cheese, yogurt: cooked beans, meat, fish and chicken; egg yolk) At 10-20 months: Whole Egg Finger Food Honey Warning: “Authorities recommend that honey not be fed to any infant for the first year of life. Honey may carry botulism spores that can be harmful to young infants and has been known to cause infant botulism. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.” (Licensing 101427.A)

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing Dept. of S.S. ADDRESS 0000 Xxxxxxxxxxxx 000 Xxx Xxxx Xx. ., Xxxxx 000 CITY San Diego XXXX Xxxxxx ZIP CODE 92108 92868 AREA CODE/TELEPHONE NUMBER (000) 000-0000000 0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) San Clemente Preschool L.L.C. 000 Xxxxxxx Xxxxxxxx, Xxx Xxxxxxxx, Xx. 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Dept. of S.S. Community Care Licensing 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Community Care Licensing Attn: Child Care Duty Officer 000 Xxxx Xxxxxx Xxxxx #A230 Rohnert Park, CA 94928 707.588.5026 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Little Lambs Preschool (PRINT THE ADDRESS OF THE FACILITY) 0000 Xxxxxxxxxx Xxxxxx Xxxxxxxxxx (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. _________________________________________________ _________________________________________________ _________________________________________________ 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Community Care Licensing | Attn: Child Care Duty Officer 000 Xxxx Xxxxxx Xxxxx #X000 | Xxxxxxx Xxxx, XX 00000 707.588.5026 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE San Diego Hebrew Day Preschool 0000 Xxxxx Xx. San Diego, CA 92123 CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) 'S NAME: As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded beaccorded dignity in hisinhis/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information ofinformation regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the bemade bythe parent(s), or guardian(s) of the child. (6) Not to be locked in any belocked inany room, building, or facility premises by day byday or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx #000 CITY San Diego ZIP CODE Diego, CA 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) San Diego Hebrew Day ECC 0000 Xxxxx Xxxxx Xxx Xxxxx XX 00000 As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing Child Care Division ADDRESS 0000 Xxxxxxxxxxxx Xx. 000 Xxx Xxxx Xxxxx Xxxxx 000 CITY San Diego Orange ZIP CODE 92108 92668 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) St. John's Episcopal School Early Childhood Ctr 00000 Xxx Xxx Xxxx, XXX, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Palmdale Regional Child Care Licensing Office ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER Palmdale 000-0000000 000-0000 ZIP CODE 93550 00000 Xxxxx Xxxxxx Xxxxx, Xxx 000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) 00000 Xxxxxxx Xxxxxx Xxxx, Xxxxx Xxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 613A 627 (8/089/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in careincare. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757755M75etMroeptorolitpaonlitDarnivDe,r.S, Suiuteite111100 CITY San Diego SanSDainegDoiego, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((661199)) 776677-0000000 -22230000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) MYMagCdAaloefnSaaEncDkeieFgaomCiloyuYnMtyCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: (000) 000-0000 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP BIRTHDATE FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? ■ CALL EMERGENCY HOSPITAL ■ OTHER EXPLAIN: NAME RELATIONSHIP TIME CHILD WILL BE CALLED FOR SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE DATE OF ADMISSION DATE LEFT STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY XXXXX’S NAME SEX BIRTH DATE FATHER’S/FATHER’S DOMESTIC PARTNER’S NAME DOES FATHER/FATHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD? MOTHER’S/MOTHER’S DOMESTIC PARTNER’S NAME DOES MOTHER/MOTHER’S DOMESTIC PARTNER LIVE IN HOME WITH CHILD? IS /HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSICIAN? DATE OF LAST PHYSICAL/MEDICAL EXAMINATION DEVELOPMENTAL HISTORY (*For infants and preschool-age children only) WALKED AT* MONTHS BEGAN TALKING AT* MONTHS TOILET TRAINING STARTED AT* MONTHS PAST ILLNESSES — Check illnesses that child has had and specify approximate dates of illnesses: DATES DATES ■ Poliomyelitis ■ Ten-Day Measles (Rubeola) ■ Three-Day Measles (Rubella) DATES ■ Chicken Pox ■ Diabetes ■ Asthma ■ Epilepsy ■ Rheumatic Fever ■ Whooping cough ■ Hay Fever ■ Mumps SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS DOES CHILD HAVE FREQUENT COLDS? ■ YES ■ NO HOW MANY IN LAST YEAR? LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF DAILY ROUTINES (*For infants and preschool-age children only) WHAT TIME DOES CHILD GET UP?* WHAT TIME DOES CHILD GO TO BED?* DOES CHILD SLEEP WELL?* DOES CHILD SLEEP DURING THE DAY?* WHEN?* HOW LONG?* DIET PATTERN: (What does child usually eat for these meals?) BREAKFAST WHAT ARE USUAL EATING HOURS? BREAKFAST LUNCH LUNCH DINNER ANY FOOD DISLIKES? ANY EATING PROBLEMS? IS CHILD TOILET TRAINED?* ■ YES ■ NO IF YES, AT WHAT STAGE:* ARE BOWEL MOVEMENTS REGULAR?* ■ YES ■ NO WHAT IS USUAL TIME?* WORD USED FOR “BOWEL MOVEMENT”* WORD USED FOR URINATION* IS CHILD PRESENTLY UNDER A DOCTOR’S CARE? ■ YES ■ NO IF YES, NAME OF DOCTOR: DOES CHILD TAKE PRESCRIBED MEDICATION(S)? ■ YES ■ NO IF YES, WHAT KIND AND ANY SIDE EFFECTS: DOES CHILD USE ANY SPECIAL DEVICE(S): ■ YES ■ NO IF YES, WHAT KIND: DOES CHILD USE ANY SPECIAL DEVICE(S) AT HOME? ■ YES ■ NO IF YES, WHAT KIND: PARENT’S EVALUATION OF CHILD’S PERSONALITY HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN? HAS THE CHILD HAD GROUP PLAY EXPERIENCES? DOES THE CHILD HAVE ANY SPECIAL PROBLEMS/FEARS/NEEDS? (EXPLAIN.) WHAT IS THE PLAN FOR CARE WHEN THE CHILD IS ILL? PARENT’S SIGNATURE DATE REASON FOR REQUESTING DAY CARE PLACEMENT As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: Sacramento Regional Office 0000 Xxxxxxx Xxxx Xxxxx, Xxxxx 000, Xxxxxxxxxx, XX 00000 (000) 000-0000 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentialityregardingconfidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: State of California Department of Social Services NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxxxxxx Xxxxxx, Xxxxx 000 CITY San Diego Goleta, CA ZIP CODE 92108 93117 AREA CODE/TELEPHONE NUMBER NUMBER(805) 000-0000000 0000 DETACH HERE P LACE IN CHILD'S FILE Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Trinity Lutheran Preschool (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxxx Xxxx, Xxxx Xxxxxx, CA 93446 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY PHYSICIAN’S REPORT—CHILD CARE CENTERS (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.CHILD’S PRE-ADMISSION HEALTH EVALUATION)

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx XxX. Xxxx Ave. Xxxxx 000 MS 29-01 CITY San Diego Fresno ZIP CODE 92108 93710 AREA CODE/TELEPHONE NUMBER (000) 000-0000000 0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Cornerstone Christian Preschool (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO _Cornerstone Christian Preschool TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (CHILD’S PRE-ADMISSION HEALTH EVALUATION) , born is being studied for readiness to enter (NAME OF XXXXX) (BIRTH DATE) . This Child Care Center/School provides a Parentprogram which extends from : (NAME OF CHILD CARE CENTER/Authorized RepresentativeSCHOOL) a. m./p.m. to a.m./p.m. , days a week. Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Speech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ (DIPHTHERIA, TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUSDT/Td AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / (REQUIRED FOR CHILD CARE ONLY)HIB MENINGITIS (HAEMOPHILUS B) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) ■ Risk factors not present; TB skin test not required. ■ Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present. ■ ■ I have have not reviewed the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee above information with the licensing office and review the licenseeparent/guardian. Physician: Date of Physical Exam: Address: Date This Form Completed: Telephone: Signature ■ Physician’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.Assistant ■ Nurse Practitioner LIC 701 (8/08) (Confidential) PAGE 1 OF 2

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: Hospital used by family: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) Child’s Name: Birth Date: Age: Parent’s Name: Phone #: Drop Off Time: Pick Up Time: Instructions from child’s pediatrician relating to special diet or feeding: List of any known allergies: Breast milk or brand of formula: Brand of formula: 6:00 a.m. 1:00 p.m. 7:00 a.m. 2:00 p.m. 8:00 a.m. 3:00 p.m. 9:00 a.m. 4:00 p.m. 10:00 a.m. 5:00 p.m. 11:00 a.m. 6:00 p.m. 12:00 p.m. 7:00 p.m. Plan for introducing solid and/or new foods: List of food child likes: Food Consistency: List of food child does not like: Plan for introducing cup/Authorized Representativeutensils at snack and mealtime: Diapering: Type: Number per day: Skin preparations: ointments, you have the right to: 1powder etc.: Plan for introducing “toilet training”: Xxxxx’s Sleeping Plan – What are your child’s sleeping habits and usual environments? Is your child able to roll over on their own? List any additional instructions or special need to provide quality care for your child: Director’s Signature: Date: Parent’s Signature: Date: *Next Conference Date: *Conference Date will be updated if there are any changes to this plan. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept “Recommendations for Infant Feeding Practices” by the licensing officeDepartment of Human Services Birth-12 months: Breast milk, iron fortified formula or evaporated milk formula At 4-6 months: Infant cereal (dry type) At 5-7 months: Vegetables, fruits and their juices At 6-8 months: Protein foods (cheese, yogurt: cooked beans, meat, fish and chicken; egg yolk) At 10-20 months: Whole Egg Finger Food Honey Warning: “Authorities recommend that honey not be fed to any infant for the first year of life. Honey may carry botulism spores that can be harmful to young infants and has been known to cause infant botulism. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.” (Licensing 101427.A)

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded beaccorded dignity in hisinhis/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information ofinformation regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the bemade bythe parent(s), or guardian(s) of the child. (6) Not to be locked in any belocked inany room, building, or facility premises by day byday or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx #000 CITY San Diego ZIP CODE Diego, CA 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) EarlyChildhoodCenter San Diego Hebrew Day 0000 Xxxxx Xxxxx Xxx Xxxxx XX 00000 As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xxxx Xx. Xxxxx , Xxx 000 CITY San Diego XXXX Xxxxxxxxx ZIP CODE 92108 92501 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Xxxxxxxx Baptist Day School (PRINT THE ADDRESS OF THE FACILITY) 00000 Xxxx Xxxx, Xxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO Xxxxxxxx Baptist Day School TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: Hospital used by family: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) Child’s Name: Birth Date: Age: Parent’s Name: Phone #: Drop Off Time: Pick Up Time: Instructions from child’s pediatrician relating to special diet or feeding: List of any known allergies: Breast milk or brand of formula: Brand of formula: 6:00 a.m. 1:00 p.m. 7:00 a.m. 2:00 p.m. 8:00 a.m. 3:00 p.m. 9:00 a.m. 4:00 p.m. 10:00 a.m. 5:00 p.m. 11:00 a.m. 6:00 p.m. 12:00 p.m. 7:00 p.m. Plan for introducing solid and/or new foods: List of food child likes: Food Consistency: List of food child does not like: Plan for introducing cup/Authorized Representativeutensils at snack and mealtime: Diapering: Type: Number per day: Skin preparations: ointments, you have the right to: 1powder etc.: Plan for introducing “toilet training”: Child’s Sleeping Plan – What are your child’s sleeping habits and usual environments? Is your child able to roll over on their own? List any additional instructions or special need to provide quality care for your child: Director’s Signature: Date: Parent’s Signature: Date: *Next Conference Date: *Conference Date will be updated if there are any changes to this plan. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept “Recommendations for Infant Feeding Practices” by the licensing officeDepartment of Human Services Birth-12 months: Breast milk, iron fortified formula or evaporated milk formula At 4-6 months: Infant cereal (dry type) At 5-7 months: Vegetables, fruits and their juices At 6-8 months: Protein foods (cheese, yogurt: cooked beans, meat, fish and chicken; egg yolk) At 10-20 months: Whole Egg Finger Food Honey Warning: “Authorities recommend that honey not be fed to any infant for the first year of life. Honey may carry botulism spores that can be harmful to young infants and has been known to cause infant botulism. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.” (Licensing 101427.A)

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), domestic partner(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/DOMESTIC PARTNER/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/DOMESTIC PARTNER/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/DOMESTIC PARTNER/GUARDIAN) (DATE) LIC 613A (8/081/08) As a Parent/Domestic Partner/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 CITY San Diego ZIP CODE 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 ZIP CODE Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (CHILD’S PRE-ADMISSION HEALTH EVALUATION) , born is being studied for readiness to enter (NAME OF XXXXX) (BIRTH DATE) . This Child Care Center/School provides a Parentprogram which extends from : (NAME OF CHILD CARE CENTER/Authorized RepresentativeSCHOOL) a. m./p.m. to a.m./p.m. , days a week. Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Speech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ (DIPHTHERIA, TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUSDT/Td AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / (REQUIRED FOR CHILD CARE ONLY)HIB MENINGITIS (HAEMOPHILUS B) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) ■ Risk factors not present; TB skin test not required. ■ Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present. ■ ■ I have have not reviewed the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee above information with the licensing office and review the licenseeparent/guardian. Physician: Date of Physical Exam: Address: Date This Form Completed: Telephone: Signature ■ Physician’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.Assistant ■ Nurse Practitioner LIC 701 (8/08) (Confidential) PAGE 1 OF 2

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 Xxxxxxx Xxx CITY San Diego Bruno ZIP CODE 92108 CA AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (5/01) (CONFIDENTIAL) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (5/01) (CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CHILD’S NAME LAST MIDDLE FIRST SEX TELEPHONE ( ) ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP BIRTHDATE FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST BUSINESS TELEPHONE ( ) HOME ADDRESS XXXXXX XXXXXX XXXX XXXXX ZIP HOME TELEPHONE ( ) PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST HOME TELEPHONE ( ) BUSINESS TELEPHONE ( ) NAME ADDRESS TELEPHONE RELATIONSHIP PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) DENTIST ADDRESS MEDICAL PLAN AND NUMBER TELEPHONE ( ) IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN? ■ CALL EMERGENCY HOSPITAL ■ OTHER EXPLAIN: NAME RELATIONSHIP TIME CHILD WILL BE CALLED FOR SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE DATE DATE OF ADMISSION DATE LEFT LIC 700 (8/08)(CONFIDENTIAL) STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (CHILD’S PRE-ADMISSION HEALTH EVALUATION) (NAME OF XXXXX) (BIRTH DATE) (NAME OF CHILD CARE CENTER/SCHOOL) a.m./p.m. to a.m./p.m. , days a Parentweek. Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Authorized RepresentativeSpeech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ (DIPHTHERIA, you TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS DT/Td AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / (REQUIRED FOR CHILD CARE ONLY) HIB MENINGITIS (HAEMOPHILUS B) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) ■ Risk factors not present; TB skin test not required. ■ Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present. I have ■ have not ■ reviewed the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee above information with the licensing office and review the licenseeparent/guardian. Physician: Address: Telephone: Date of Physical Exam: Date This Form Completed: Signature LIC 701 (8/08) (Confidential) ■✔ Physician ■✔ Physician’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.Assistant ■✔ Nurse Practitioner

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded beaccorded dignity in hisinhis/her personal relationships with staff and other persons. (2) To be accorded safeTobeaccordedsafe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information ofinformation regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a ona completely voluntary basis. In Child InChild Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made bemade by the parent(s), or guardian(s) of the ofthe child. (6) Not to be locked in any belocked inany room, building, or facility premises by day byday or night. (7) Not to be placed in any beplaced inany restraining device, except a supportive restraint approved in advance by the licensing thelicensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx #000 CITY San Diego ZIP CODE CA 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE San Diego Hebrew Day Preschool 0000 Xxxxx Xx. San Diego, CA 92123 CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) 'S NAME: As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMMUNITY CARE LICENSING ADDRESS 0000 Xxxxxxxxxxxx XxXXXXXXX XXXX XX. Xxxxx 000 STE 250 CITY San Diego SACRAMENTO ZIP CODE 92108 95833 AREA CODE/TELEPHONE NUMBER (000) 000-0000000 0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) LINCOLN LEARNING CENTER (PRINT THE ADDRESS OF THE FACILITY) 000 XXXXXX XXXX XX XXXXXXX 95648 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY (CHILD’S PRE-ADMISSION HEALTH EVALUATION) (NAME OF XXXXX) (BIRTH DATE) (NAME OF CHILD CARE CENTER/SCHOOL) a.m./p.m. to a.m./p.m. , days a Parentweek. Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center. (SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE) Problems of which you should be aware: Hearing: Allergies: medicine: Vision: Insect stings: Developmental: Food: Language/Authorized RepresentativeSpeech: Asthma: Dental: Other (Include behavioral concerns): Comments/Explanations: MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD: POLIO (OPV OR IPV) / / / / / / / / / / DTP/DTaP/ (DIPHTHERIA, you TETANUS AND [ACELLULAR] PERTUSSIS OR TETANUS DT/Td AND DIPHTHERIA ONLY) / / / / / / / / / / MMR (MEASLES, MUMPS, AND RUBELLA) / / / / (REQUIRED FOR CHILD CARE ONLY) HIB MENINGITIS (HAEMOPHILUS B) / / / / / / / / HEPATITIS B / / / / / / VARICELLA (CHICKENPOX) / / / / SCREENING OF TB RISK FACTORS (listing on reverse side) ■ Risk factors not present; TB skin test not required. ■ Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented). Communicable TB disease not present. I have ■ have not ■ reviewed the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee above information with the licensing office and review the licenseeparent/guardian. Physician: Address: Telephone: Date of Physical Exam: Date This Form Completed: Signature ■✔ Physician ■✔ Physician’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.Assistant ■✔ Nurse Practitioner

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded beaccorded dignity in hisinhis/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information ofinformation regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the bemade bythe parent(s), or guardian(s) of the child. (6) Not to be locked in any belocked inany room, building, or facility premises by day byday or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx #000 CITY San Diego ZIP CODE Diego, CA 92108 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE FACILITY) (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) San Diego Hebrew Day Preschool 0000 Xxxxx Xxxxx Xxx Xxxxx XX 00000 As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s 's public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing NAME Sacramento Regional Office ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx Xxxxxxx Xxxx Xx Xxx 000 CITY San Diego Sacramento DETACH HERE ZIP CODE 92108 95833 AREA CODE/TELEPHONE NUMBER 000-0000000 000-0000 TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) (PRINT THE ADDRESS OF THE OFTHE FACILITY) (PRINT THE PRINTTHE NAME OF THE CHILDCHILO) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. (4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality. (5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child. (6) Not to be locked in any room, building, or facility premises by day or night. (7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency. THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS: NAME Community Care Licensing COMCoMmUmNuITnYityCCAaRreE LLiIcCeEnNsiSngING ADDRESS 0000 Xxxxxxxxxxxx Xx. Xxxxx 000 757357M37etMroapionliStatn., DSruivitee,7S0u0ite 110 CITY San Diego SanRDivieegrsoide, CA ZIP CODE 92108 0000000000 AREA CODE/TELEPHONE NUMBER 000((691591) 776872-0000000 -24200 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment: (PRINT THE NAME OF THE FACILITY) Xxxxxxxxx Xxxx Family YMCA (PRINT THE ADDRESS OF THE FACILITY) 000 Xxxxxx Xxxx, Xxxxxxxxx, XX 00000 (PRINT THE NAME OF THE CHILD) (SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE) LIC 613A (8/08) STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO FACILITY NAME PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR NAME WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE. CHILD HAS THE FOLLOWING MEDICATION ALLERGIES: DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE HOME ADDRESS HOME PHONE WORK PHONE ( ) ( ) LIC 627 (9/08) (CONFIDENTIAL) As a Parent/Authorized Representative, you have the right to: 1. Enter and inspect the child care center without advance notice whenever children are in care. 2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office. 3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years. 4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child. 5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order. 6. Receive from the licensee the name, address and telephone number of the local licensing office. Licensing Office Name: Licensing Office Address: Licensing Office Telephone #: 0000 Xxxx Xx., Xxxxx 000, Xxxxxxxxx, XX 00000 (000) 000-0000 7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office. 8. Receive, from the licensee, the Caregiver Background Check Process form.