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When entrusting a child to the care of a daycare center or family child care home, safety and well-being are paramount. The Lic 627 form plays a crucial role in ensuring that children receive necessary medical attention swiftly, especially in emergencies. This form, officially known as the Consent for Emergency Medical Treatment, is necessary for parents or authorized representatives to grant explicit permission to care facilities. It allows designated caregivers to secure emergency medical or dental care from licensed professionals, such as physicians or dentists, on behalf of the child. By completing the Lic 627, parents acknowledge their child's medication allergies and the vital conditions that may necessitate immediate intervention. This simple yet essential document fosters peace of mind, ensuring that medical care can be administered promptly, prioritizing the child's health and safety in any unexpected situation. By clearly stating the required details, including the child's name, facility name, and contact information, the Lic 627 form streamlines the process of obtaining essential medical treatment when it matters most.

Lic 627 Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-

Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE

FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER

NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

DATE

PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

HOME ADDRESS

HOME PHONE

( )

WORK PHONE

( )

LIC 627 (9/08) (CONFIDENTIAL)

Get Lic 627 PDF Form

Form Characteristics

Fact Name Fact Description
Purpose The LIC 627 form is used to provide consent for emergency medical or dental treatment for children in child care settings.
Governing Law The use of the LIC 627 form is governed by California Health and Safety Code Section 1596.875.
Applicable Settings This form is applicable in both child care centers and family child care homes in California.
Signature Requirement A parent or authorized representative must sign the form, granting consent for medical treatment.
Emergency Provision The form states that treatment may occur under whatever conditions are necessary to preserve the child's well-being.
Allergies Disclosure Parents must disclose any medication allergies their child has on the form to ensure safety during treatment.
Confidentiality Note The form is marked as confidential, indicating that the information provided will be kept private.
Version Date The current version of the LIC 627 form is from September 2008, as indicated on the form itself.

Guidelines on Utilizing Lic 627

Completing the Lic 627 form is an important step for ensuring that your child receives the necessary emergency medical care when you are not available. When filling it out, take your time to ensure all information is accurate and legible. Following the steps below can help streamline the process and minimize any confusion.

  1. Begin by writing the name of the emergency medical or dental care facility in the designated space.
  2. Next, enter your child's name clearly in the space provided for "NAME".
  3. Specify any medication allergies your child has in the section titled "CHILD HAS THE FOLLOWING MEDICATION ALLERGIES".
  4. Sign the form where indicated to give your consent. Make sure your signature matches your name printed on the document.
  5. Provide your home address, including street, city, state, and zip code.
  6. Fill in your home phone number, ensuring you include the area code. Make sure to double-check for accuracy.
  7. Lastly, enter your work phone number, including the area code as well.

After completing these steps, review the form to ensure all details are correct. Keeping a copy for your records is also advisable. Once satisfied, submit the form to the designated authority at your child’s care facility.

What You Should Know About This Form

What is the purpose of the LIC 627 form?

The LIC 627 form is a consent document that allows parents or authorized representatives to give permission for emergency medical treatment for children enrolled in child care centers or family child care homes. This ensures that childcare providers can quickly obtain necessary medical care in emergency situations, preserving the health and safety of the child.

Who needs to sign the LIC 627 form?

The form must be signed by a parent or an authorized representative of the child. This individual is responsible for making medical decisions on behalf of the child and is typically a legal guardian or someone designated to act in the parent’s stead.

What information is required on the LIC 627 form?

Key information needed on the LIC 627 form includes the name of the child, the name of the health facility or physician designated to provide care, and the signatures of the parent or authorized representative. Additionally, it is essential to list any medication allergies the child has, ensuring that medical providers can avoid potentially harmful treatments.

Is the LIC 627 form confidential?

Yes, the LIC 627 form is marked as confidential. This confidentiality remains paramount, as it contains personal health information regarding the child that should be protected in accordance with privacy regulations.

When should the LIC 627 form be completed?

The LIC 627 form should be completed before the child begins attending a child care center or family child care home. It is advisable to have this information ready, so caregivers can act swiftly in case of an emergency.

What happens if I don’t complete the LIC 627 form?

Failure to complete the LIC 627 form may delay necessary medical treatment in an emergency. Child care providers may not be authorized to seek medical attention without prior consent, potentially placing the child's health at risk.

Can I revoke consent after signing the LIC 627 form?

Yes, consent can be revoked after signing the LIC 627 form. However, it is crucial to communicate this decision promptly to the child care provider, ensuring they are informed and can act appropriately based on the most current instructions.

Where should I keep the completed LIC 627 form?

The completed LIC 627 form should be kept in a safe and accessible location. It is wise to provide a copy to the child care provider so they have it readily available in case of an emergency.

Are there any fees associated with obtaining the LIC 627 form?

No fees are associated with completing the LIC 627 form, as it is a standard form provided by the California Department of Social Services for use in child care settings.

Can I add additional information to the LIC 627 form?

While the LIC 627 form has specific fields that must be filled out, if there is additional information you feel is important—such as chronic health conditions or emergency contacts—it's advisable to discuss this directly with the child care provider to ensure all relevant information is available for emergencies.

Common mistakes

Filling out the LIC 627 form is an important step for parents and authorized representatives to ensure their child receives timely medical care in emergencies. However, several common mistakes can lead to complications. One frequent error is leaving the child’s name blank. Omitting the name means that medical professionals cannot clearly identify which child the consent applies to, potentially delaying care when every second counts.

Another common mistake is failing to provide the name of the medical care facility on the form. When this space is left empty, it can create confusion for medical providers who might need to check records or contact the facility. Parents should take care to ensure that they fill this section accurately to avoid any issues during an emergency.

In addition, many people neglect to list any known medication allergies in the appropriate section. This information is crucial for healthcare providers. If a child has allergies and the medical team is unaware, it could lead to administering treatments that pose serious risks. Always double-check that this part of the form is completed thoroughly.

Another oversight is providing incorrect contact information. Parents often forget to include up-to-date phone numbers or addresses. This can be problematic during a crisis, as providers need to reach parents or guardians quickly. It is essential to maintain accurate information; otherwise, it could hinder communication when it’s most needed.

Signing the form is vital, yet some individuals overlook this step. Without a signature, the document cannot be considered valid. It is important to ensure that someone who is authorized, rather than just any caretaker, fills out and signs the form. This adds a layer of legitimacy to the consent.

People also sometimes mistakenly assume that the date is irrelevant. Failing to date the form can lead to issues later on. Even if a form appears to be complete, a missing date might raise questions, causing unnecessary delays in emergency situations.

Forgetting to mention emergency contacts is another issue. The form allows for additional emergency contacts to be listed, yet many parents skip this section. Providing alternative contacts can be essential in scenarios where the primary guardian cannot be reached.

A common mistake is not using clear and legible handwriting when filling out the form. Illegible writing can render the information unreadable to medical professionals. This can be easily avoided by taking the time to write neatly or, if possible, typing the information to ensure clarity.

Lastly, some parents may be unsure about who qualifies as an “authorized representative.” Misunderstanding who is eligible can result in delays or complications during an emergency. Ensure clear identification of the person giving consent, as it is vital for the document's effectiveness.

Documents used along the form

When managing the health and safety of children in childcare settings, certain forms and documents are commonly utilized along with the Lic 627 form. These documents help ensure proper consent and communication regarding a child's well-being. Here is a list of several forms that often accompany the Lic 627.

  • Emergency Contact Form: This document lists individuals authorized to be contacted in case of an emergency. It typically includes their names, relationships to the child, and contact information.
  • Health History Form: This form provides essential information about the child's medical background, including past illnesses, surgeries, and ongoing health issues. It helps caregivers understand specific health needs.
  • Medication Authorization Form: A critical document that permits caregivers to administer prescribed medications during childcare hours. It includes details on medication types, dosages, and administration times.
  • Injury Report Form: Should an accident occur, this form is used to document the incident, including specifics like time, place, and nature of the injury. It serves as an official record for both the childcare provider and parents.

Having these documents available ensures that childcare providers and parents can work together effectively. Essential childcare decisions can be made quickly and safely, prioritizing the health of every child in their care.

Similar forms

  • Consent for Medical Treatment Form - Similar to the Lic 627, this document authorizes medical professionals to perform necessary medical treatments for a child. Like the Lic 627, it outlines crucial information regarding the child's health and parental consent.
  • Emergency Contact Form - This form serves to provide emergency contacts for a child, much like the Lic 627. It ensures that caregivers can quickly reach out to responsible individuals in case of an emergency.
  • Authorization for Release of Medical Records - This document allows healthcare providers to share a child’s medical history with authorized parties. Both the Lic 627 and this authorization facilitate timely medical action when necessary.
  • Medication Administration Consent Form - This form gives permission for caregivers to administer specific medications. Similar to the Lic 627, it emphasizes the importance of parental consent in medical care.
  • Child Health Assessment Form - A document that collects health information about a child, akin to the Lic 627. It helps caregivers understand the child's medical needs and allergies, ensuring appropriate care during emergencies.

Dos and Don'ts

When filling out the Lic 627 form, there are important do's and don'ts to keep in mind. Following these guidelines helps ensure accurate completion and compliance.

  • Do provide clear and accurate information for the facility name.
  • Do specify the child's full name correctly.
  • Do list any medication allergies to ensure safety.
  • Do sign the form personally if you are the parent or an authorized representative.
  • Do include all relevant contact information: home address and phone numbers.
  • Don’t leave any required fields blank.
  • Don’t use abbreviations or nicknames for the child's name.
  • Don’t forget to check the form for accuracy before submission.
  • Don’t panic if you make a mistake; corrections can be made by drawing a line through the error and writing the correct information.
  • Don’t hesitate to ask for help if you’re unsure about any part of the form.

Misconceptions

Understanding the Lic 627 form is crucial for parents and authorized representatives involved in childcare. Unfortunately, several misconceptions can create confusion. Here are nine common myths about the Lic 627 form, along with clarifications:

  • It’s only for emergencies. Many believe the Lic 627 form is only necessary in life-threatening situations. In reality, it allows caregivers to obtain necessary medical care promptly, even when the situation isn’t dire.
  • All child care providers have their own forms. Some think that each child care center or family child care home requires a unique set of forms. In truth, the Lic 627 form is standardized and approved for use across California.
  • I don’t need to complete it if my child has no known allergies. Some may feel that skipping the section on allergies is harmless. However, it’s essential to fill out all relevant sections to ensure caregivers have complete information about your child.
  • The form must be notarized. There’s a misconception that the Lic 627 form requires notarization for it to be valid. This is not true; a parent or authorized representative's signature is sufficient.
  • I can verbally consent instead of completing the form. While verbal consent may seem convenient, caregivers typically require the completed Lic 627 form to ensure they have documented permission in case of an emergency.
  • Once signed, the consent is permanent. Some parents worry that signing the form gives up their rights permanently. However, consent is generally applicable only until the end of care or until it is revoked by the parent.
  • The form covers all medical procedures. There’s a belief that the Lic 627 form covers any medical intervention without limits. In reality, it specifically pertains to emergency medical or dental care as prescribed by licensed professionals.
  • My signature means I’m liable for any medical care provided. This misconception leads many to fear signing the form. The consent allows treatment but does not make a parent liable for the care provided by the facility.
  • It’s only necessary if I’m not available. Many think the form is only needed if they cannot be reached during an emergency. However, it’s beneficial for all parents to complete it to facilitate swift medical attention if necessary.

By dispelling these misconceptions, parents can feel more confident in understanding and using the Lic 627 form effectively.

Key takeaways

When filling out the Lic 627 form, keep these key takeaways in mind:

  1. Provide accurate information. Ensure that the facility name, child's name, and your signature are clearly written.
  2. Understand the breadth of consent. By signing, you authorize emergency medical care that might be necessary to protect your child's health.
  3. List any allergies. Include specific medication allergies your child has to prevent adverse reactions during treatment.
  4. Update your contact information. Make sure your home and work phone numbers are current, enabling quick communication during emergencies.
  5. Keep the form accessible. Store a copy at the child care facility to ensure it can be easily retrieved when needed.

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