CALIFORNIA 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 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
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
Dated: __________________________ Signed:
_________________________________________
(See
back of this form for Notices and Additional Information)
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 one year after the date on which it is executed.
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 nay 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.
4.
If you do not
have the information required in item 8 (
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 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.