Fill and Sign the Circuit Court for Maryland Request for Order of Default Maryland Courts Form

CAREGIVER’S AUTHORIZATION AFFIDAVIT A. Completion of Items 1-4 and signing the affidavit is sufficient to authorize enrollment of a minor in school and authorize school-related medical care. B. Completion of Items 5-8 is additionally required to authorize any other medical, dental or mental health care. PRINT CLEARLY:The minor named below lives in my home and I am 18 years of age or older. 1. Name of minor: ___________________________________________________________. 2. Minor’s birth date: __________________________________________________________. 3. My name (adult giving authorization):___________________________________________. 4. My home address: _________________________________________________________. 5. ( ) I am a grandparent, aunt, uncle or other qualified relative of the minor. (See bottom of this form for a definition of qualified relative.) 6. Check one or both (for example, if one parent was advised and the other cannot be located): ( ) I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection. ( ) I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this time, to notify them of my intended authorization. 7. My date of birth: ___________________________________________________________. 8. My driver’s license or other identification card number: ___________________________. WARNING: Do not sign this form if any of the statements above are incorrect, or you will be committing a crime punishable by a fine, imprisonment or both. I declare under penalty of perjury under the laws of the state of ________________ (Name of State) that the foregoing is true and correct. Signed: _____________________________________________ ACKNOWLEDGMENT The foregoing affidavit was subscribed, sworn to and acknowledged before me by ________________________________________ this _____ day of _____________ 20____. ____
.................................................................... I certify that I am at least 21 years of age. ................................................................................................ I further certify that I am of the following adult age(s): . I certify that I have been advised of the nature of this form by the ................................................................................. Signature of the above adult guardian. I agree to read, understand and obey the terms of this signature and that the above adult who signed this form understands and desires his/her signature to remain valid as an authorization given by him/her. (signature lines may be completed only by one minor.) no signatures will be accepted from any person under 18 years of age, except the minor (a parent, aunt, uncle or other qualified relative) indicated in item (c) if the minor named below lives in my home and I am 18 years of age or older. I also agree that, if the minor (parent, aunt, uncle or other relative) is unable to be located, I will also indicate the name of the parent, aunt, uncle or other relative so that he/she may be contacted if the parent, aunt, uncle or other relative would like to be notified when such minor is residing in my home and the parent, aunt, uncle or other relative would like to authorize health care. By signing this form, my signature and the witness signatures below indicate that I have read, understood and understand these terms. If any of the statements in this signature are incorrect and my name is or has previously been used by another person or organization, I waive my right to be represented by my own attorney. Please contact my office for an on-site visit concerning my eligibility for this program. In my determination, I have reviewed, checked and/or verified my identification and address information herein, and have fully examined the entire contents of this form. I have reviewed the minor's eligibility for the program (including, but not limited to, age, citizenship, residency and health care needs)(a) and (b) and have checked if (a) this form has been signed by the applicable parent, adult guardian and physician for the minor (if known), or (b) i (and an adult who is at least 21 years of age) have personally obtained the signature in this form from the minor (if known) while he/she resides in my home and I am 18 years of age or older. (see the bottom of this form for a definition of qualified relative.) in case of any conflict between my signature on this form and the other signature on this form