Navigation
Free download music sights need sun we why youtube video watch 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____. ____
Sign up and try Free download music sights need sun we why youtube video watch form
No credit card required
Try template
No credit card required
  • Close deals faster
  • Improve productivity
  • Delight customers
  • Increase revenue
  • Save time & money
  • Reduce payment cycles