Temporary Authorization For Kinship Care (Page 8 of 8) in pdf

Temporary Authorization For Kinship Care Page 8

see, discuss and receive any mental health records, and/or approve any mental health treatment or

services for the child(ren).

see, discuss and receive any other confidential information about the child(ren)

take the child(ren) to a house of worship and provide religious education.

enroll the child(ren) in school

consent to participation in extra-curricular school activities

receive, deliver, and pay money due to the child(ren)

receive any other information or take any actions that are needed to ensure the well-being of the

child(ren)

All of the above

Other (please describe)___________________________________________________________

What the Kinship Caregiver is not Authorized To Do – OPTIONAL SECTION

Under Michigan law, the Kinship Caregiver may not allow the child (ren) to be adopted or to agree to

their marriage. In addition, the kinship caregiver may not do any of the following without my prior

written permission (check any or all that apply):

Move more than _______miles from the caregiver’s current address.

Change the state where the caregiver currently lives.

Take the child out of the United States of America.

Authorize tattoos, piercings, or cosmetic surgery.

Other (please describe): __________________________________________________________

______________________________________________________________________________

When this Authorization Starts and Ends

This authorization is in effect as soon as it is signed. It can be used in all states. A copy is just as valid

as the original. It will stay in effect even if the custodial parent(s) become disabled or incapacitated.

This authorization expires automatically 6 months after it is signed [or if a parent is serving in the mili-

tary in a foreign nation, 31 days after the parent’s deployment] or on this earlier date

________________ unless I renew or revoke it before then. If I want to revoke it, I can do so at any

time and in any way that shows clearly what I want to do. If I do not revoke it in writing, anyone who

sees me revoke it may describe the circumstances in writing and sign it.

Signature of Parent(s): (Sign in front of a notary public. If both parents have custody of the children,

both must sign).

Parent

The person(s) above appeared before me, identified themselves, and signed this document voluntarily

on this _____ day of

, 200___.

Notary Public,

County,

State of Michigan, My Commission Expires:

Temporary Authorization For Kinship Care Page 8