Bumo | Licensing Set (Center+Family Home)

Bumo | License Forms
Email Address*

Confirmation EmailConfirm Email Address
Which state's forms need to be filled out?*
Please CLICK HERE to access and download the correct forms to fill out.

When filled out, please send the completed forms including your child's immunization records to licensing at bumo.com. :)

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PARENT/AUTHORIZED REPRESENTATIVE NAME (Primary Contact)*

First NameLast Name
CHILD'S NAME*

First NameLast Name
Is this child enrolled in another school or program?*

YesNo
What school or program is this child enrolled in?*
What city is the school or program located in?*
Does your child have any cognitive or developmental conditions or challenges that we should be aware of?*

YesNo
Please provide us with any relevant information so that we can better support your child's needs.*

	What does the child usually eat for these meals?
BREAKFAST
LUNCH
DINNER

	When does the child usually eat these meals?
BREAKFAST
LUNCH
DINNER

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LIC 613A (8/08)
PERSONAL RIGHTS

Child Care Centers
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.

(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.
TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

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 the child care center.
NAME OF THE CHILD*
SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN*

Clear
NAME OF THE REPRESENTATIVE/PARENT/GUARDIAN*
DATE*

MonthDayYear
Date

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LIC 700 (10/19) (CONFIDENTIAL)
IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS / FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative
CHILD’S NAME*

FIRSTLAST
SEX*
PRIMARY TELEPHONE NUMBER*
ADDRESS*

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
BIRTHDATE*

MonthDayYear
PARENT / AUTHORIZED REPRESENTATIVE NAME (Primary Contact)*

FIRSTLAST
HOME ADDRESS*

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
HOME TELEPHONE*
BUSINESS TELEPHONE
PARENT / AUTHORIZED REPRESENTATIVE NAME (Secondary Contact) [CONTACT 2]

FIRSTLAST
CONTACT 2 HOME ADDRESS

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE
Add a Secondary Contact?*

YesNo
CONTACT 2 HOME/CELL TELEPHONE
CONTACT 2 BUSINESS TELEPHONE
PERSON RESPONSIBLE FOR CHILD*

FIRSTLAST
HOME TELEPHONE*
BUSINESS TELEPHONE
ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

	NAME	ADDRESS	TELEPHONE	RELATIONSHIP
1
2
3
4

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY
PHYSICIAN'S NAME*
(PHYSICIAN)
PHYSICIAN'S ADDRESS*
(PHYSICIAN)
MEDICAL PLAN AND NUMBER*
(PHYSICIAN)
PHYSICIAN'S TELEPHONE*
(PHYSICIAN)
DENTIST'S NAME*
(DENTIST)
DENTIST'S ADDRESS*
(DENTIST)
DENTAL PLAN AND NUMBER*
(DENTIST)
DENTIST'S TELEPHONE*
(DENTIST)
If the physician cannot be reached, what action should be taken?*

Call emergency hospitalOther (Explain below)
NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)
Authorized Pick-Up 1*

First NameLast Name
Authorized Pick-Up 1 Relationship to Child*
Authorized Pick-Up 2*

First NameLast Name
Authorized Pick-Up 2 Relationship to Child*
Authorized Pick-Up 3

First NameLast Name
Authorized Pick-Up 3 Relationship to Child
Add more authorized pick-ups?

YesNo
Authorized Pick-Up 4

First NameLast Name
Authorized Pick-Up 4 Relationship to Child
Authorized Pick-Up 5

First NameLast Name
Authorized Pick-Up 5 Relationship to Child
TIME CHILD WILL BE PICKED UP*
SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE*

Clear
DATE*

MonthDayYear
Date
TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE
DATE OF ADMISSION

MonthDayYear
Date
DATE OF LAST ENROLLMENT

MonthDayYear
Date

CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS
PARENTS' RIGHTS
As a Parent/Authorized Representative, you have the right to:
1. Enter and inspect the child care center without advance notice whenever children are in care.
2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office.
3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last three years.
4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.
5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have shown a certified copy of a court order.
6. Receive from the licensee the name, address and telephone number of the local licensing office.
7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.
8. Receive, from the licensee, the Caregiver Background Check Process form.
NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice “Registered Sex Offender” database, go to www.meganslaw.ca.gov
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS’ RIGHTS
I, the parent/authorized representative of CHILD'S NAME* , have received a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and the CAREGIVER BACKGROUND CHECK PROCESS form from the licensee.
Facility Address*
Signature (Parent/Authorized Representative)*

Clear
Date*

MonthDayYear
NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given to parent/authorized representative.

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
LIC 627 (9/08) (CONFIDENTIAL)
CONSENT FOR EMERGENCY MEDICAL TREATMENT

Child Care Centers Or Family Child Care Homes
AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO THE FACILITY TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR CHILD NAME*. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.
CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:*
DATE*

MonthDayYear
Date
PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE*

Clear
HOME ADDRESS*
HOME PHONE*
WORK PHONE
Is your child under the age of 2 years old?*

YesNo

AFFIDAVIT REGARDING LIABILITY INSURANCE FOR

FAMILY CHILD CARE HOME

I/We, the parent(s)/guardian(s) of {childsName} acknowledge that the licensee of this family child care home has informed me/us that this facility does not carry liability insurance or a bond in accordance with standards established by Family Child Care statute.

SECTION B: To be completed only if licensee does not own premises or the licensee is a member of a condominium or Homeowner's Association.

I/We, the parent(s)/guardian(s) of {childName} acknowledge that the licensee of this family child care home, has informed me/us that she/he does not own the premises or is a member of a condominium or Homeowner's Association, and the liability insurance, if any, of the owner/Homeowners' Association may not provide coverage for losses arising out of, or in connection with, the operation of the family child care home, except to the extent that the losses are caused by, or result from, an action or omission by the owner/Homeowners' Association, for which the owner/Homeowners Association would otherwise be liable under the law.
NEBULIZER CARE CONSENT/VERIFICATION CHILD CARE FACILITIES
Does your child require a staff member to administer inhaled medication to your child?*

YesNo
NAME OF THE CHILD*
I, {parentauthorizedRepresentative333}, give my consent for the staff, to administer inhaled medication to my child, {childsName}, and to contact my child’s health care
provider.

(Please instruct the staff person on how to administer inhaled medication to your child. Provide the child care facility with written instructions from your child’s physician, or from a health care provider working under the supervision of my child’s physician (for example, a physician’s assistant, nurse practitioner or registered nurse)
Signature*

Clear
FAMILY CHILD CARE HOME NOTIFICATION OF PARENTS' RIGHTS
As a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the family child care home without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee's public file kept by the licensing office.

3. Review, at the family child care home, reports of licensing visits and substantiated complaints against the licensee made during the last three years.

4. Complain to the licensing office and inspect the family child care home without discrimination or retaliation against you or your child.

5. Be notified and receive, from the licensee, a written notice that lists the name of any person not allowed in the family child care home while children are present. (NOTE: This notice is only required when the Department has, in writing, excluded someone from the family child care home on or after January 1, 2001)

6. Request in writing that a parent not be allowed to visit your child or take your child from the family child care home, provided you have shown a certified copy of a court order.

7. Receive from the licensee the name, address and telephone number of the local licensing office.

8. Be informed by the licensee, upon request, of the name and type of association to the family child care home for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

9. Receive, from the licensee, the Caregiver Background Check Process form.

10. Be informed, by the licensee, that the facility has or does not have liability insurance (or a bond) that covers injury to clients due to the negligence of the licensee or employees of the facility.

NOTE:CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

For the Department of Justice "Registered Sex ffender"database, go to www.meganslaw.ca.gov
ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS
I, the parent/authorized representative of, {childsName}, have received a copy of the "FAMILY CHILD CARE HOME NOTIFICATION OF PARENTS' RIGHTS", the CAREGIVER BACKGROUND CHECK PROCESS and the FAMILY CHILD CARE CONSUMER AWARENESS INFORMATION form from the licensee. (Viewable and Downloadable below)
Signature Parent/Authorized Representative*

Clear
IMMUNIZATIONS
Please upload a copy of your child's immunization records. If you do not have them ready, please submit this form still then email them to licensing@bumo.com at least 24 hours before the first session.

Cancelof
Should be Empty:

	YES	DATES
Chicken Pox
Asthma
Rheumatic Fever
Hay Fever
Diabetes
Epilepsy
Whooping Cough
Mumps
Poliomyelitis
Ten-Day Measles (Rubeola)
Three-Day Measles (Rubella)

Bumo | License Forms

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CHILD’S PRE-ADMISSION HEALTH HISTORY

DEVELOPMENTAL HISTORY

PAST ILLNESSES

DAILY ROUTINES

PERSONAL RIGHTS

IDENTIFICATION AND EMERGENCY INFORMATION CHILD CARE CENTERS / FAMILY CHILD CARE HOMES

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS

PARENTS' RIGHTS

ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS’ RIGHTS

CONSENT FOR EMERGENCY MEDICAL TREATMENT

NEBULIZER CARE CONSENT/VERIFICATION CHILD CARE FACILITIES

FAMILY CHILD CARE HOME NOTIFICATION OF PARENTS' RIGHTS

ACKNOWLEDGEMENT OF NOTIFICATION OF PARENTS' RIGHTS

IMMUNIZATIONS