Form Pr-E-Lp-023 - Caregiver'S Authorization Affidavit Page 2
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2PR-E-LP-023
ADDITIONAL INFORMATION
TO CAREGIVERS:
1) “Qualified relative”, for purposes of item 5, means a spouse, parent, stepparent, brother, sister,
stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any
person denoted by the prefix “grand” or “great” or the spouse of any of the persons specified in
this definition, even after the marriage has been terminated by death or dissolution.
2) The law may require you, if you are not a relative or a currently licensed foster parent, to obtain a
foster home license in order to care for a minor. If you have any questions, please contact your
local department of social services.
3) If the minor stops living with you, your are required to notify any school, health care provider, or
health care service plan to which you have given this affidavit.
4) If you do not have the information requested in item 8 (California driver’s license or I.D.), provide
another form of identification such as your social security number or Medi-Cal number.
TO SCHOOL OFFICIALS:
1) Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis for a
determination of residency of the minor, without the requirement of a guardianship or other
custody order, unless the school district determines from actual facts that the minor is not living
with the caregiver.
2) The school district may require additional reasonable evidence that the caregiver lives at the
address provided in item 4.
TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:
1) No person who acts in good faith reliance upon a caregiver’s authorization affidavit to provide
medical or dental care, without actual knowledge of facts contrary to those dated on the affidavit,
is subject to criminal liability or to civil liability to any person, or is subject to professional
disciplinary action, for such reliance if the applicable portions of the form are completed.
2) This affidavit does not confer dependency for health care coverage purposes.
Page 2 of 2
PR-E-LP-023 (Revised October 11, 2011)
CAREGIVER’S AUTHORIZATION AFFIDAVIT
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