JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
PERSONAL RIGHTS
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:
Name
*
Your answer
Address
*
Your answer
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
*
Your answer
ADDRESS OF THE FACILITY
*
Your answer
NAME OF THE CHILD
*
Your answer
FULL NAME OF THE CHILD
*
Your answer
FULL NAME OF PARENT/GUARDIAN
*
Your answer
TITLE OF PARENT/GUARDIAN
*
Your answer
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
