Fillable California Caregiver Authorization Affidavit Form printable pdf download

California Caregiver Authorization Affidavit Form

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Caregiver Authorization Affidavit

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.

I AFFIRM THAT THE FOLLOWING INFORMATION IS TRUE AND CORRECT:

MINOR:

1. Name: ___________________________________________________________

2. Birthdate: ________________________________________________________

CAREGIVER INFORMATION:

My name (adult giving authorization): _________________________________

My home address: _________________________________________________

_________________________________________________

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

( ) I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back of this form

for a definition of "qualified relative").

Check one or both (for example, if one parent was advised and the other cannot be located):

( ) I have advised the parent(s) or other persons(s) having legal custody of the minor of my

intent to authorize medical care and have received no objection.

( ) I am unable to contact the parent(s) or other person(s) having legal custody of the minor

at this time, to notify them of my intended authorization.

My date of birth: _____________________________________________________

My California driver's license or identification care number: ___________________

WARNING: Do no 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.

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

foregoing is true and correct.

DATED: __________________

SIGNED: _________________________________

SEE NOTICES ON THE BACK OF THIS PAGE

CAREGIVER AUTHORIZATION AFFIDAVIT

California Caregiver Authorization Affidavit Form

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