Authorization Agreement For Nonparent Relative Or Voluntary Caregiver

AUTHORIZATION AGREEMENT

August 2011

Page 2 of 4

FOR NONPARENT RELATIVE OR

VOLUNTARY CAREGIVER

Parent authorizes the above named relative or voluntary caregiver to perform the following acts in

regard to the child and the relative or voluntary caregiver assumes the responsibility of

performing these functions:

(1) To authorize medical, dental, psychological, surgical treatment, and immunization of the child,

including executing any consents or authorizations for the release of information as required by law

relating to the treatment or immunization;

(2) To obtain and maintain health insurance coverage for the child and automobile insurance coverage

for the child, if appropriate;

(3) To enroll the child in a day-care program or public or private preschool, primary or secondary school;

iate extracurricular, civic, social, or recreational

To authorize the child to participate in age-appropr

(4)

activities, including athletic activities;

(5) To authorize the child to obtain a learner's permit, driver's license, or state-issued identification card;

(6) To authorize employment of the child; and

(7)

To apply for and receive public benefits on behalf of the child.

(8) This authorization agreement does not confer on the relative or voluntary caregiver of the child the

right to authorize the performance of an abortion on the child or the administration of emergency

contraception to the child

To the best of the parent's and the relative's or voluntary caregiver's knowledge (check if applicable):

This child is not the subject of a current (pre-existing) valid authorization agreement, and no

parent, guardian, custodian, licensed child-placing agency or other agency makes any claim to

actual physical possession or care, custody or control of the child that is inconsistent with this

authorization agreement.

ntary caregiver's knowledge (choose one from below):

To the best of the parent's and the relative's or volu

THERE IS NO COURT INVOLVEMENT WITH THIS CHILD

All of the following statements must apply:

•

There is no court order or pending suit affecting the parent-child relationship concerning the child.

There is no pending litigation in any court concerning custody, possession, or placement of the

•

child or access to or visitation with the child.

•

The court does not have continuing jurisdiction concerning the child.

THIS CHILD HAS BEEN THE SUBJECT OF A COURT ACTION

The court with continuing jurisdiction concerning the child has given written appr

oval for the execution of

the authorization agreement accompanied by the following information:

•

The county in which the court is located;

•

The number of the court; and

•

The cause number in which the order

was issued or the litigation is pending.

Please staple a copy of the court's order to this agreement.

Authorization Agreement For Nonparent Relative Or Voluntary Caregiver - Texas Page 2

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