Caretaker Affidavit Form

Caregiver's Authorization Affidavit

Use of this affidavit is authorized by Part 1.5 (commencing
with Section 6550) of Division 11 of the California Family
Code.

Instructions: Completion of items 1-4 and the signing of
the affidavit is sufficient to authorize enrollment of
a minor in school and authorize school-related medical
care. Completion of items 5-8 is additionally required to
authorize any other medical 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 back 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 California driver's license or 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 California that the foregoing is true and correct.
Dated: _______________________ Signed: _________________________

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.

Additional Information:

TO CAREGIVERS:

1. "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, or
any person denoted by the prefix "grand" or "great," or the spouse of
any of the persons specified in this definition, even after the
marriage has been terminated by death or dissolution.

2. The law may require you, if you are not a relative or a currently
licensed foster parent, to obtain a foster home license in order to
care for a minor. If you have any questions, please contact your
local department of social services.

3. If the minor stops living with you, you are required to notify
any school, health care provider, or health care service plan to
which you have given this affidavit. The affidavit is invalid after
the school, health care provider, or health care service plan
receives notice that the minor no longer lives with you.

4. If you do not have the information requested in item 8
(California driver's license or I.D.), provide another form of
identification such as your social security number or Medi-Cal
number.

TO SCHOOL OFFICIALS:

1. Section 48204 of the Education Code provides that this affidavit
constitutes a sufficient basis for a determination of residency of
the minor, without the requirement of a guardianship or other custody
order, unless the school district determines from actual facts that
the minor is not living with the caregiver.

2. The school district may require additional reasonable evidence
that the caregiver lives at the address provided in item 4.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

1. A person who acts in good faith reliance upon a caregiver's
authorization affidavit to provide medical or dental care, without
actual knowledge of facts contrary to those stated on the affidavit,
is not subject to criminal liability or to civil liability to any
person, and is not subject to professional disciplinary action, for
that reliance if the applicable portions of the form are completed.

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

 

 

 

.