Caretaker Authorization Affidavit Form - Hamilton County Juvenile Court (Page 4 of 4) in pdf

Caretaker Authorization Affidavit Form - Hamilton County Juvenile Court Page 4

affidavit does not preclude the parent, guardian, or custodian of the child from having access to all school

records pertinent to the child.

2. The school district may require additional reasonable evidence that the grandparent lives at the address

provided in item 5.

3. A school district or school official that reasonably and in good faith relies on this affidavit has no obligation

to make any further inquiry or investigation.

4. The act of a parent, guardian, or custodian of the child to negate, reverse, or otherwise disapprove an action

or decision of the grandparent who signed this affidavit constitutes termination of this affidavit. A parent,

guardian, or custodian may negate, reverse, or disapprove a grandparent's action or decision only by delivering

written notice of negation, reversal, or disapproval to the grandparent and the person acting on the grandparent's

action or decision in reliance on this affidavit.

To health care providers:

1. A person or entity that acts in good faith reliance on a CARETAKER AUTHORIZATION AFFIDAVIT to

provide medical, psychological, or dental treatment, without actual knowledge of facts contrary to those stated

in the affidavit, is not subject to criminal liability or to civil liability to any person or entity, and is not subject to

professional disciplinary action, solely for such reliance if the applicable portions of the form are completed and

the grandparent's signature is notarized.

2. The decision of a grandparent, based on a CARETAKER AUTHORIZATION AFFIDAVIT, shall be

honored by a health care facility or practitioner, school district, or school official unless the health care facility

or practitioner or educational facility or official has actual knowledge that a parent, guardian, or custodian of a

child has made a contravening decision to consent to or to refuse medical treatment for the child.

3. The act of a parent, guardian, or custodian of the child to negate, reverse, or otherwise disapprove an action

or decision of the grandparent who signed this affidavit constitutes termination of this affidavit. A parent,

guardian, or custodian may negate, reverse, or disapprove a grandparent's action or decision only by delivering

written notice of negation, reversal, or disapproval to the grandparent and the person acting on the grandparent's

action or decision in reliance on this affidavit.

Page 4 of 4

Form 1345

Caretaker Authorization Affidavit Form - Hamilton County Juvenile Court Page 4