Caregiver'S Authorization Affidavit (Page 2 of 2) in pdf

Caregiver'S Authorization Affidavit Page 2

CAREGIVER'S AUTHORIZATION AFFIDAVIT

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Completion of Items 1 -4 and signing the affidav it 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, dental or mental health

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care.

Name of Minor

Minor's birthdate

Caregiver's Name

Caregiver's Home Address

I am a grandparent, aunt, uncle or other qualified relativ e of the minor.

(See back or following page for a definition of "qualified relativ e.")

Check one or both (for ex ample, if one parent was adv ised and other cannot be located)

I hav e adv ised the parent(s) or other person(s) hav ing legal custody of the minor

of my intent to authorize medical care, and hav e receiv ed no objection.

I am unable to contact the parent(s) or other person(s) hav ing legal custody

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

Caregiver's Birthdate

Caregiver's Driver's License or other 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 last of the state of New Mex ico that the foregoing is

true and correct.

CAREGIVER'S SIGNATURE

NOTARY PUBLIC ACKNOWLEDGMENT

(Photo Identification, Signature Witnessing & Notary Seal Required)

This affidavit was subscribed, sworn to and acknowledged before me this,

the ____________ day of the month of _______________________, 201 _____.

NOTARY PUBLIC

My Commission Expires

(Seal)

This Form is authorized by New Mexico Statute: 40-10B-15 NMSA 1978.

Caregiver'S Authorization Affidavit Page 2