Caregiver Authorization Affidavit
ADVERTISEMENT
1
2CAREGIVER AUTHORIZATION AFFIDAVIT
Massachusetts General Laws Chapter 201F
1. AUTHORIZING PARTY (Parent/Guardian)
I, ____________________________, residing at __________________________________
am:
the parent
legal guardian
legal custodian
of the minor child(ren) listed
(circle one)
below.
I do hereby authorize ____________________________________________, residing at
______________________________________________ to exercise concurrently the rights
and responsibilities, except those prohibited below, that I possess relative to the education and
health care of the minor children whose names and dates of birth are:
______________________________
___________________________________
name
date of birth
name
date of birth
______________________________
___________________________________
name
date of birth
name
date of birth
The caregiver may NOT do the following: (If there are any specific acts you do not want the
caregiver to perform, please state those acts here.)
____________________________________________________________________________
____________________________________________________________________________
The following statements are true: (Please read)
• There are no court orders in effect that would prohibit me from exercising or conferring
the rights and responsibilities that I wish to confer upon the caregiver. (If you are the
legal guardian or custodian, attach the court order appointing you.)
• I am not using this affidavit to circumvent any state or federal law, for the purposes of
attendance at a particular school, or to re-confer rights to a caregiver from whom those
rights have been removed by a court of law.
• I confer these rights and responsibilities freely and knowingly in order to provide for the
child(ren) and not as a result of pressure, threats or payments by any person or agency.
• I understand that, if the affidavit is amended or revoked, I must provide the amended
affidavit or revocation to all parties to whom I have provided this affidavit.
This document shall remain in effect until ____________(not more than two years from today)
or until I notify the caregiver in writing that I have amended or revoked it.
I hereby affirm that the above statements are true, under pains and penalties of perjury.
Signature
:
_________________________________
Printed name
:
_________________________________
Telephone number
:
_________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal