Caregiver’s Authorization Affidavit

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 I 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

Notary Public

My Commission expires:

NOTICES:

1. This declaration does not affect the rights of the minor's parents or legal guardian regarding the care, custody and control of the minor, and does not mean that the caregiver has legal custody of the minor.

2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.

3. This affidavit is not valid for more than (Number) year(s) after the date on which it is executed.

Additional Information:

TO CAREGIVERS:

1. Caregiver means, an adult, who is not a parent of the child, with whom a child resides and who provides that child with the care, maintenance and supervision consistent with the duties and responsibilities of a parent of the child.

2. Qualified Relative for purposes of Item 5, means a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, godparent, member of the child's tribe or clan, an adult with whom the child has a significant bond or any person denoted by the prefix "grand” or “great”, or the spouse or former spouse of any of the persons specified in this definition.

3. School-related medical care for purposes of Items 1-4, means medical care that is required by the state or a local government authority as a condition for school enrollment.

4. If the minor stops living with you, you are required to notify any school, health care provider, mental health care provider, health insurer or other person to whom you have given this affidavit.

5. If you do not have the information requested in Item 8, provide another form of identification such as your social security number or Medicaid number.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

1. No person who acts in good faith reliance upon a caregiver's authorization affidavit to provide medical, dental or mental health care, without actual knowledge of facts contrary to those stated on the affidavit, is subject to criminal liability or to civil liability to any person, or is subject to professional disciplinary action, for such reliance if the applicable portions of the form are completed.

2. This affidavit does not confer dependency for health care coverage purposes.