Authorization Agreement For Nonparent Relative Or Voluntary Caregiver - Texas Page 4
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4AUTHORIZATION AGREEMENT
August 2011
Page 4 of 4
FOR NONPARENT RELATIVE OR
VOLUNTARY CAREGIVER
who signed the agreement or any child of the parent who signed the agreement; or
2. The non-signing parent has been convicted of any of the following criminal offenses against
the parent who signed the agreement or any ch
ild of the parent who signed the agreement:
any offense under Title 5 of the Texas Penal Code (including murder, homicide,
o
kidnapping, assault and sexual assault); or
any other criminal offense in Texas or any other state if the offense involves a violent act
o
or prohibited sexual conduct.
This authorization agreement (select one of the following two):
Expires on this date:
OR
Is valid until revoked in writing by either party
In addition, check here if you want the agreement to continue in effect after your death or during any
period of incapacity.
Execution of a subsequent authorization agreement does not by itself supersede, invalidate, or terminate
a prior authorization agreement.
By signing below, parent and the relative or volunt
ary caregiver acknowledge that they have each read
into the authorization agreement voluntarily, and have
this authorization agreement carefully, are entering
read and understand all of the Warnings and Disclosures included in this authorization agreement.
________________________
_____________
PARENT
Printed name:
SUBSCRIBED AND ACKNOWLEDGED BEFORE ME on this ____ day of _________________, 20____.
_____________________________________
Notary Public in and for the State of TEXAS
________________________
_____________
PARENT**
Printed name:
SUBSCRIBED AND ACKNOWLEDGED BEFORE ME on this ____ day of _________________, 20____.
_____________________________________
Notary Public in and for the State of TEXAS
________________________
_____________
RELATIVE OR VOLUNTARY CAREGIVER
Printed name:
SUBSCRIBED AND ACKNOWLEDGED BEFORE ME on this ____ day of _________________, 20____.
_____________________________________
Notary Public in and for the State of TEXAS
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