PARENT NOTIFICATION ADDITIONAL CHILDREN IN CARE *

As required by Health and Safety Code Sections 1597.44(c) and 1597.465(c), you are hereby notified that:

I am licensed as a Small Family Child Care Home and may provide care for more than six and up to eight children when one child is enrolled in and attending kindergarten (including transitional kindergarten) or elementary school, and another child is at least six years old, and no more than two infants are in care. Address: 489 Montecito Drive, Corte Madera CA 94925

RECEIPT OF PARENT NOTIFICATION Additional Children in Care *

I acknowledge receipt of the notification that this Small Family Child Care Home may be providing care for more than six and up to eight children, or that this Large Family Child Care Home may be providing care for more than 12 and up to 14 children in accordance with Health and Safety Code Sections 1597.44 and 1597.465.

Parent Name *

First Name

Last Name

Today's Date *

MM

DD

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Child Name *

First Name

Last Name

As a Parent/Authorized Representative, you have the right to: *

1. Enter and inspect the family child care 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 home, 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 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: SAN BRUNO REGIONAL OFFICE Licensing Office Address: 851 Traeger Avenue, suite 360 San Bruno, CA 94066 Licensing Office Telephone #: 650-266-8800 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. 10. Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that covers injury to clients due to the negligence of the licensee or employees of the facility. NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE. LIC 995A (8/08) For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to the parent/authorized representative. LIC 995A (8/08)

I, the parent/authorized representative of [child's name], have received a copy of the “FAMILY CHILD CARE HOME NOTIFICATION OF PARENTS’ RIGHTS”, the CAREGIVER BACKGROUND CHECK PROCESS and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the licensee [EPIC COOKING SCHOOL]

Acknowledgement *

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers. (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: San Bruno Regional Office 851 Traeger Avenue, Suite 360, San Bruno, CA 94066 650-266-8800 Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

I/We have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to: EPIC COOKING SCHOOL located at 489 Montecito Drive, Corte Madera, CA 94925 for:

Child Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Child's Name *

First Name

Last Name

Child's Sex *

Male

Female

Other

Child's Phone *

(###)

###

####

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Birth Date *

MM

DD

YYYY

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

First Name

Last Name

FATHER’S/GUARDIAN’S Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

FATHER’S/GUARDIAN’S Business Telephone

(###)

###

####

FATHER’S/GUARDIAN’S Home Telephone

(###)

###

####

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

First Name

Last Name

MOTHER’S/GUARDIAN’S Business Telephone

(###)

###

####

MOTHER’S/GUARDIAN’S Home Telephone

(###)

###

####

MOTHER’S/GUARDIAN’S Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PERSONAL RESPONSIBLE FOR CHILD *

First Name

Last Name

Telephone

(###)

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####

Emergency Contact 1 Name

First Name

Last Name

Emergency Contact 1 Phone

(###)

###

####

Emergency Contact 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact 2 Name

First Name

Last Name

Emergency Contact 2 Phone

(###)

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####

Emergency Contact 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician Name

First Name

Last Name

Physician Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician Phone Number

(###)

###

####

Dentist Name

First Name

Last Name

Dentist Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dentist Phone Number

(###)

###

####

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

CALL EMERGENCY HOSPITAL

OTHER

Authorized Name 1 *

First Name

Last Name

Authorized Name 2 (Optional)

First Name

Last Name

Authorized Name 3 (Optional)

First Name

Last Name

Authorized Name 4 (Optional)

First Name

Last Name

CONSENT FOR EMERGENCY MEDICAL TREATMENT *

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO EPIC COOKING SCHOOL TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR MY CHILD. THIS CARE MAY BE GIVEN UNDER WHATEVER NAME CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.

Today's Date

MM

DD

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PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

First Name

Last Name