Form Pr-E-Lp-023 - Caregiver'S Authorization Affidavit
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2PR-E-LP-023
CAREGIVER’S AUTHORIZATION AFFIDAVIT
Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the
California Family Code.
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
through 8 is additionally required to authorize any other medical care. Print clearly.
The minor named below lives in my home and I am 18 years of age or older.
1.
Name of minor: ______________________________________________________________
2.
Minor’s birth date: ____________________________________________________________
3.
My name: __________________________________________________________________
(adult giving authorization)
4.
My home address: __________________________________________________________
__________________________________________________________
5.
[ ]
I am a grandparent, aunt, uncle, or other qualified relative of the minor
(see back of this
form for a definition of “qualified relative”).
6.
Check one or both
(for example, if one parent was advised and the other cannot be located):
[ ]
I have advised the parent
or other person
having legal custody of the minor of my
(s)
(s)
intent to authorize medical care, and have received no objection.
[ ]
I am unable to contact the parent
or other person
having legal custody of the
(s)
(s)
minor at this time, to notify them of my intended authorization.
7.
My date of birth: _____________________________________________________________
8.
My California driver’s license or identification card number: ___________________________
Warning: Do not 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: _________________________________________
NOTICES
1. This declaration does not affect the rights of the minor’s parents or legal guardian
regarding the care, custody, and control of the minor, and does not mean that the caregiver
has legal custody of the minor.
2. A person who relies on this affidavit has no obligation to make any further inquiry or
investigation.
3. This affidavit is not valid for more than one year after the date on which it is executed.
Page 1 of 2
PR-E-LP-023 (Revised October 11, 2011)
CAREGIVER’S AUTHORIZATION AFFIDAVIT
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