STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CHILD CARE FACILITY ROSTER
(RETAIN FOR 3 YEARS)
CHILD CARE CENTERS, INFANT CARE
CENTERS, SCHOOL AGE CENTERS
AND FAMILY CHILD CARE HOMES
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.
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.
FACILITY NAME:
FACILITY LICENSE NUMBER: DATE/UPDATE:
CHILD’S NAME/
BIRTHDATE
ADDRESS
PARENT/GUARDIAN
NAME(S)
DAYTIME PHONE OF
PARENT/GUARDIAN
PHYSICIAN NAME
AND PHONE
DATE
ENROLLED
DATE
LEFT
LIC 9040 (10/05)
