PERSONAL RIGHTS
Email address *
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
Name *
Address *
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:
NAME OF THE FACILITY *
ADDRESS OF THE FACILITY *
NAME OF THE CHILD *
FULL NAME OF THE CHILD *
FULL NAME OF PARENT/GUARDIAN *
TITLE OF PARENT/GUARDIAN *
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