Caregiver'S Authorization Affidavit Form And Instructions printable pdf download

COURT

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COUNTY OF

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Index No.

Caregiver's Authorization Affidavit

Calendar No.

Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of

JUDICIAL SUBPOENA

Plaintiff(s)

Division 11 of the California Family Code.

-against-

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.

Defendant(s)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The minor named below lives in my home and I am 18 years of age or older.

1. Name of minor: ______________________________.

THE PEOPLE OF THE STATE OF NEW YORK

2. Minor's birth date: _____________________.

3. My name (adult giving authorization): _______________________________.

4. My home address (street, apartment number, city, state, zip code):

______________________________________________

GREETINGS:

______________________________________________

WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before

______________________________________________

the Honorable

at the

Court

located at

County of

I am a grandparent, aunt, uncle, or other qualified relative of the minor

in room

, on the

day of

, 20

, at

o'clock in the

noon, and at any recessed

(see page 2 of this form for a definition of "qualified relative").

or adjourned date, to testify and give evidence as a witness in this action on the part of the

6. Check one or both (for example, if one parent was advised and the other

cannot be located):

Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to

I have advised the parent(s) or other person(s) having legal

the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a

custody of the minor of my intent to authorize medical care, and

result of your failure to comply.

have received no objection.

I am unable to contact the parent(s) or other person(s)

Witness, Honorable

, one of the Justices of the

having legal custody of the minor at this time, to notify them of

Court in

County,

day of

, 20

my intended authorization.

7. My date of birth: ______________________.

(Attorney must sign above and type name below)

8. My California's driver's license or identification card number: ____________.

Attorney(s) for

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.

Office and P.O. Address

I declare under penalty of perjury under the laws of the State of California that

the foregoing is true and correct.

Telephone No.:

Dated: _____________________

Signed: ________________________

Facsimile No.:

E-Mail Address:

Mobile Tel. No.:

California Courts Self-Help Center

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Caregiver'S Authorization Affidavit Form And Instructions

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