California Department of Social Services (CDSS) Community Care Licensing Child Care Forms Packet (LIC 9150, LIC 282, LIC 627, LIC 700, LIC 995A, CDPH 286, LIC 9227) Instructions

Enter the initials of the staff member who reviewed the pupil’s immunization record for 7th grade advancement or admission.

Check this box if the pupil has received all required vaccine doses for 7th grade and no follow-up is needed.

Check this box if the pupil has a current temporary medical exemption for required vaccines.

Check this box if the pupil is missing required doses that are not currently due and is allowed conditional admission pending future doses.

Check this box if the pupil is missing required doses that are overdue and needs to receive the doses now.

Enter the date(s) for any required follow-up actions or appointments related to 7th grade immunization requirements. Fill only if '7th Grade - Temporary Medical Exemption', '7th Grade - Missing Doses Not Currently Due (Conditional)', '7th Grade - Missing Doses Are Overdue (Needs Doses Now)' is 'Yes' (any).

Enter the date when the pupil met all immunization requirements for 7th grade advancement or admission.

Check this box if the 'IEP' designation applies to the pupil's follow-up or admission status for 7th grade.

Check this box if the 'IND' designation applies to the pupil's follow-up or admission status for 7th grade.

Check this box if the 'Home' designation (home instruction/home schooling) applies to the pupil's follow-up or admission status for 7th grade.

Enter the full name of the primary authorized representative who will serve as the main contact for the infant (first and last name).

Enter the phone number for the primary authorized representative, including area code and any necessary punctuation or extension so staff can reach them.

Enter the full name of the authorized representative who will serve as the secondary contact for the infant.

Enter the phone number for the secondary contact authorized representative so they can be reached regarding the infant.

Enter the full printed name or signature of the authorized representative certifying that the information on the form is complete and accurate.

Enter the date when the authorized representative signed the form.

Enter the average number of minutes the infant naps during the daytime (minutes only).

Enter the average number of hours the infant naps during the daytime (hours only).

Enter the date when the parent or authorized representative signed the emergency medical treatment consent.

Enter the date the pupil received the first DTaP/DTP/Tdap/Td dose.

Enter the date the pupil received the second DTaP/DTP/Tdap/Td dose.

Enter the date the pupil received the third DTaP/DTP/Tdap/Td dose.

Enter the pupil's age in years when the third DTaP/DTP/Tdap/Td dose was given.

Enter the date the pupil received the fourth DTaP/DTP/Tdap/Td dose.

Enter the pupil's age in years when the fourth DTaP/DTP/Tdap/Td dose was given.

Enter the date the pupil received the fifth DTaP/DTP/Tdap/Td dose.

Check this box when the pupil has a documented permanent medical exemption that exempts them from the DTaP/DTP/Tdap/Td vaccine requirement.

Enter the full mailing street address of the facility, including number, street name, unit or suite if any, city, state and ZIP code.

Enter the full legal name of the child care facility or family child care home as it appears on its license or official records.

Enter the date the first Hepatitis B vaccine dose was administered for this pupil.

Enter the date the second Hepatitis B vaccine dose was administered for this pupil.

Enter the date the third Hepatitis B vaccine dose was administered for this pupil.

Check this box only if the pupil has an approved permanent medical exemption from the Hepatitis B (Hep B) vaccination requirement.

Enter the date the child's first Hib (Haemophilus influenzae type b) vaccine dose was given.

Enter the date the child's second Hib (Haemophilus influenzae type b) vaccine dose was given.

Enter the date the child's third Hib (Haemophilus influenzae type b) vaccine dose was given.

Enter the date the child's fourth Hib (Haemophilus influenzae type b) vaccine dose was given.

Check this box if the pupil has a permanent medical exemption from the Hib (Haemophilus influenzae type b) vaccine.

Enter the infant's full name as shown elsewhere on this form.

Enter the month when the infant first began rolling (numeric month, e.g., 01 for January).

Enter the day of the month when the infant first began rolling (numeric day, e.g., 05).

Enter the year when the infant first began rolling (four-digit year, e.g., 2024).

Enter the infant's full legal name (first, middle, and last as applicable).

Enter the infant's gender (e.g., Male, Female, Non-binary, or another descriptor as preferred).

Provide the infant's date of birth.

Enter the time of day when the infant usually finishes their second (secondary) sleeping period or nap.

Enter the time of day when the infant usually starts their second (secondary) sleeping period or nap.

Enter the time of day when the infant usually starts their first (primary) sleeping period.

Enter the time of day when the infant usually finishes their first (primary) sleeping period.

Enter the date the 1st IPV/OPV (Polio) vaccine dose was administered to the pupil.

Enter the date the 2nd IPV/OPV (Polio) vaccine dose was administered to the pupil.

Enter the date the 3rd IPV/OPV (Polio) vaccine dose was administered to the pupil.

Enter the pupil's age in years at the time the 3rd IPV/OPV (Polio) dose was given.

Enter the date the 4th IPV/OPV (Polio) vaccine dose was administered to the pupil.

Check this box if the student has a permanent medical exemption from the IPV/OPV (polio) vaccine requirement.

Check this box if the infant does not have a medical exemption.

Check this box if the infant has a medical exemption.

Enter any medication allergies the child has; include the name of each medication and a brief note about the reaction or severity, or write 'None' if the child has no medication allergies.

Enter the date the student received the first MMR vaccine dose.

Enter the student's age in months when the first MMR dose was given.

Enter the date the student received the second MMR vaccine dose.

Check this box when the student has a documented permanent medical exemption from the MMR (Measles, Mumps, Rubella) vaccination.

Check this box if you are licensed as a Small Family Child Care Home and may legally provide care for more than six and up to eight children under the specified conditions (one child enrolled in kindergarten or elementary school, another child at least six years old, and no more than two infants in care).

Check this box if you are licensed as a Large Family Child Care Home and, with an assistant provider, may legally provide care for more than 12 and up to 14 children under the specified conditions (one child enrolled in kindergarten or elementary school, another child at least six years old, and no more than three infants in care).

Check this box if the infant uses a pacifier (answer: Yes).

Check this box if the infant does not use a pacifier (answer: No).

Check this box if the infant uses a pacifier only sometimes or intermittently.

Enter the brand name of the pacifier the infant uses (leave blank if the infant does not use a pacifier). Fill only if 'Pacifier Use — Yes' is 'Yes'.

Enter the parent or guardian's full name in the order Last name, First name (include middle name or initial if desired).

Enter the date when the parent(s) or guardian(s) signed this affidavit.

Enter the signature or printed full name of the parent(s) or guardian(s) who are signing this affidavit.

Enter any medication allergies the child has (or write 'None' if there are no known medication allergies).

Enter the child's full home address including street address, city, state, and ZIP code.

Enter the home phone number excluding the area code (enter the local number portion only).

Enter the work phone number excluding the area code (enter the local number portion only).

Enter the 3-digit area code for the home phone.

Enter the 3-digit area code for the work phone.

Enter the date the individual infant sleeping plan was created or finalized.

Enter the initials of the staff member who reviewed the pupil’s immunization record for pre-kindergarten.

Check this box when the pupil has received all vaccines required for Pre-Kindergarten (Child Care/Preschool) enrollment.

Check this box when the pupil has a current temporary medical exemption on file that exempts them from one or more required vaccines.

Check this box when the pupil is missing required doses that are not yet due and may be admitted conditionally until those doses become due.

Check this box when the pupil is missing required doses that are past due and must receive those doses immediately or before continued attendance.

Enter the follow-up date(s) for any required actions, conditional admission scheduling, or exemption follow-up related to the pupil’s pre-kindergarten immunization status. Fill only if 'Temporary Medical Exemption', 'Missing Doses Not Currently Due — Conditional', 'Missing Doses Are Overdue — Needs Doses Now' is 'Yes' (any).

Check this box when a different status applies (for example IEP, IND, Home); record the appropriate code from the form's reverse side.

Enter the date when the pupil satisfied all pre-kindergarten immunization requirements.

Check this box if the pupil identifies as Hispanic or Latino.

Check this box if the pupil does not identify as Hispanic or Latino.

Enter the pupil’s gender as requested by the form (e.g., Male, Female, Non-binary, or other designation) in this text box.

Check this box if the pupil identifies as African American or Black.

Check this box if the pupil identifies as American Indian or Alaska Native.

Check this box if the pupil identifies as Asian.

Check this box if the pupil identifies as Native Hawaiian or Other Pacific Islander.

Check this box if the pupil identifies as White.

Check this box if the pupil identifies with a race not listed above.

If the pupil’s race is not listed in the checkboxes, type the specific race or racial background here to specify the 'Other' selection. Fill only if 'Other (Race)' is 'Yes'.

Enter the pupil's full name in the order Last, First, Middle as it should appear on school records.

Enter the pupil's Statewide Student Identifier number assigned by the California education system.

Enter the pupil's date of birth.

Enter the full name of the parent or authorized representative who acknowledges receipt of the parent notification.

Enter the date when the parent or authorized representative signed to acknowledge receipt of the notification.

Enter the full name of the child to whom this receipt/acknowledgement applies.

Enter the full name of the child for whom the parent(s)/guardian(s) are completing this affidavit.

Enter the full name of the licensee (the person who operates or is listed on the child care license).

Enter the legal or commonly used name of the family child care home where care is provided.

Enter the full name of the child for whom the parent(s)/guardian(s) are signing in this Section B acknowledgement.

Enter the full legal name of the licensee (the individual who holds the family child care license) being acknowledged in Section B.

Enter the official name of the family child care home (business or facility name) that the licensee operates.

Enter the authorized representative’s signature or printed name to confirm they agree with the infant’s ability-to-roll statement in Section C.

Enter the date when the authorized representative signed the Section C statement.

Enter the authorized representative's signature or printed name to confirm they observed the infant's ability to roll in child care.

Enter the date when the authorized representative signed to confirm the observation (date of signature).

Enter the full name signature of the provider who observed the infant’s ability to roll.

Enter the date the provider signed to confirm the observation.

Enter the specific sleep location at home when it is not a crib or play yard (for example: bassinet, parent's bed, car seat, swing, floor mat, etc.). Fill only if 'Other (Specify)' is 'Yes'.

Check this box if the infant sleeps in a crib at home.

Check this box if the infant sleeps in a play yard (pack-and-play) at home.

Check this box if the infant sleeps in a location other than a crib or play yard at home, and specify that location on the line provided.

Enter the date the student's Tdap (7th grade) vaccine dose was given.

Enter the student's age in years at the time the Tdap dose was given (use whole years).

Check this box if the pupil has received one Tdap dose at age 7 years or older that satisfies the 7th-grade Tdap vaccination requirement.

Enter the initials of the staff member who reviewed this pupil’s immunization record for TK/K-12 status.

Check this box when the TK/K-12 pupil has received all required vaccine doses for school entry.

Check this box when the TK/K-12 pupil has a temporary medical exemption from immunization requirements.

Check this box when the TK/K-12 pupil is missing required doses that are not currently due and may be allowed conditional enrollment.

Check this box when the TK/K-12 pupil is missing required vaccine doses that are overdue and needs those doses immediately.

Enter the date or dates when follow-up actions or communications were scheduled or performed for this pupil’s TK/K-12 immunization requirements. Fill only if 'TK/K-12 — Temporary medical exemption', 'TK/K-12 — Missing doses not currently due (conditional)', 'TK/K-12 — Missing doses are overdue — needs doses now' is 'Yes' (any).

Check this box when the IEP (Individualized Education Program) status applies to the TK/K-12 pupil for follow-up.

Check this box when the 'IND' condition shown under Other applies to the TK/K-12 pupil for follow-up.

Check this box when the Home condition applies to the TK/K-12 pupil for follow-up (e.g., home-based instruction).

Enter the date on which the pupil’s TK/K-12 immunization requirements were satisfied.

Enter the short alphanumeric code or identifier shown in the top-right corner of the form (used for tracking or versioning).

Enter the date the first varicella (chickenpox) vaccine dose was administered for the student.

Enter the date the second varicella (chickenpox) vaccine dose was administered for the student, if applicable.

Check this box if the pupil has a permanent medical exemption from the VAR/VZV (varicella/chickenpox) vaccine.