Caregiver Authorization Form - State Of Louisiana Department Of Education
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STATE OF LOUISIANA
DEPARTMENT OF EDUCATION
POST OFFICE BOX 94064, BATON ROUGE, LOUISIANA 70804-9064
Toll Free #: 1-877-453-2721
Revised March, 2008
Caregiver Authorization Form
Title X, Part C of NCLB, McKinney-Vento Homeless Assistance Act
Instructions:
Complete this form when presenting a child/youth for enrollment who is not in the physical custody of a
parent or legal guardian.
To authorize the enrollment in school of a minor, complete items 1 through 4 and sign the
form.
To authorize the enrollment and school-related medical care of a minor, complete all
items and sign the form.
I am 18 years of age or older and have agreed to fulfill the role of caregiver for the minor named below.
1.
Name of minor: ______________________________________________________________
Minor’s date of birth: ________________________________________________________
2.
3.
My name (adult giving authorization): ____________________________________________
4.
My home address: ___________________________________________________________
5.
Check one or both statements if applicable below:
_____ I have advised the parent(s) or other person(s) having legal custody of the minor as to
my intent to authorize medical care and have received no objection.
_____ I am unable to contact the parent(s) or legal guardian(s) at this time to notify them of my
intended authorization.
6. My date of birth: ____________________________________________________________
7. My state driver’s license or identification card number: ______________________________
I declare under penalty of perjury under the laws of this state that the foregoing information is true
and correct.
Signature: ______________________________________________ Date: ________________
NOTE: This form is not required as condition for enrollment and should be used to obtain information on the
“caregiver”. This form does not require notarization nor does it address child custody issues.
“An Equal Opportunity Employer”
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