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Get CA LIC 9040 2005-2021

FACILITY NAME FACILITY LICENSE NUMBER CHILD S NAME/ BIRTHDATE LIC 9040 10/05 ADDRESS PARENT/GUARDIAN NAME S DAYTIME PHONE OF DATE/UPDATE PHYSICIAN NAME AND PHONE DATE ENROLLED LEFT. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTE This roster must be kept in a central location at the facility updated as needed and made available to the licensing agency upon request. CHILD CARE FACILITY ROSTER RETAIN FOR 3 YEARS CHILD CARE CENTERS INFANT CARE CENTERS SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES Health and Safety Code Section 1596. 841 requires that each child care facility maintain a current roster of children who are provided care in the facility. The roster shall include the child s name address names and day phone numbers of the parent s or guardian s and name and phone number of the child s physician* This is an optional form that may be used for this purpose. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTE This roster must be kept in a central location at the facility updated as needed and made available to the licensing agency upon request. CHILD CARE FACILITY ROSTER RETAIN FOR 3 YEARS CHILD CARE CENTERS INFANT CARE CENTERS SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES Health and Safety Code Section 1596. CHILD CARE FACILITY ROSTER RETAIN FOR 3 YEARS CHILD CARE CENTERS INFANT CARE CENTERS SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES Health and Safety Code Section 1596. 841 requires that each child care facility maintain a current roster of children who are provided care in the facility. 841 requires that each child care facility maintain a current roster of children who are provided care in the facility. The roster shall include the child s name address names and day phone numbers of the parent s or guardian s and name and phone number of the child s physician* This is an optional form that may be used for this purpose. STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTE This roster must be kept in a central location at the facility updated as needed and made available to the licensing agency upon request. CHILD CARE FACILITY ROSTER RETAIN FOR 3 YEARS CHILD CARE CENTERS INFANT CARE CENTERS SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES Health and Safety Code Section 1596. 841 requires that each child care facility maintain a current roster of children who are provided care in the facility. CHILD CARE FACILITY ROSTER RETAIN FOR 3 YEARS CHILD CARE CENTERS INFANT CARE CENTERS SCHOOL AGE CENTERS AND FAMILY CHILD CARE HOMES Health and Safety Code Section 1596. 841 requires that each child care facility maintain a current roster of children who are provided care in the facility. The roster shall include the child s name address names and day phone numbers of the parent s or guardian s and name and phone number of the child s physician* This is an optional form that may be used for this purpose. .

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