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Form SS-4 California San Bernardino: What You Should Know

This form is for providers. You must complete and sign one (1) form for each child. Complete and sign “Live-In Provider Statement for Self-Therapy and/or Treatment of Infants” (Form SS-4). If the child has been certified by Live-In Program, but only 1 child lives with the parent, only one (1) form will be required. This form must be completed by the parent(s) and the other parent(s) must sign it. Self-Therapy and/or Treatment of Infants (Form SS-4). (1) Signature of Provider. Please enter the following information in the space provided on the Form SS-4. I.D. (if required). 2. Name, address. 3: Date and place of birth. V. Name of Children to be Registered as Residents. If Children are Resident, add Child number (if applicable). Note: Note: You will need a copy of the original “Child” (birth/adoption papers) as well as a copy of the current copy of the birth/adoption papers. 4. Name of Preschool Provider. If school is not registered, provide information to include location with name of school and address. Name of Preschool Program. 5: Name(s) of any Registered Staff for program as well as the names of any registered staff on payroll (if applicable). Name of Preschool Program Staff. If school is registered with program staff, then provide the name of school staff as well as the name of the program staff and the location where staff works. Name of Preschool Program Staff. 6: Location where the child is currently enrolled. If the child is not enrolled in a program listed on the form, provide full name. If the child is not enrolled in a school that is currently registered with the program, state whether the child is enrolled in a school that is currently registering with the Children's Services and/or State. If the child is enrolled in a “Free” School: Name of School. 7. Name of Preschool Program. Please indicate if program is a school or a Preschool Program. 8. Name of school that the child was enrolled from. For a school that is not currently registered with the program, state the name if name of school.

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