Fillable LIC279B LIC 279B

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LIC279B LIC 279B

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CURRENT CHILDREN IN YOUR HOME
APPLICATION FOR A FAMILY CHILD CARE HOME LICENSE
Please list the name, date of birth, sex and relationship of each child living in your home. This form is
intended for agency use only and is relevant to the Application for a Family Child Care Home License,
LIC 279.
The information contained in this form is not public. This form will be filed in the confidential section of
the facility file.
CHILD’S FULL NAME DATE OF BIRTH SEX RELATIONSHIP
LIC 279B (10/05) PERSONAL/CONFIDENTIAL
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LIC279B LIC 279B

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Completed 22 June 2020

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