Caregiver's Authorization Affidavit

Caregiver's Authorization Affidavit

Patient Name

First NameLast Name

Date of Birth

Date

I am requesting to authorize school-related medical care. (Complete items 1-4)

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

1. Name of minor:

First NameLast Name

2. Minor's birthdate:

Date

3. My name (adult giving authorization):

First NameLast Name

4. My home address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In addition to school-related medical care, I am requesting to authorize all other medical, behavioral health services, or dental care. (Complete Items 5-8)

5. My relationship to the minor is that of (see Qualified Relatives below)

6. Check one of the following:

I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical or dental care, and have received no objection.I am unable at this time to contact the parent(s) or other person(s) having legal custody of the minor, to notify them of my intended authorization.

My date of birth:

Date

My California driver’s license, or other identification, number

WARNING: Do not sign this form if any statement above are untrue, or you will be committing a crime punishable by 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.

Type Name

First NameLast Name

Signature

Date

Important Information

“Qualified Relative” = spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any other 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. If the minor stops living with you, you are required to notify any school, healthcare provider, or healthcare plan to which you have given this affidavit.
If the minor stops living with you, you are required to notify any school, healthcare provider, or healthcare plan to which you have given this affidavit.
This declaration does not affect the rights of the minor’s parent(s) or legal guardian(s) regarding the care, custody, and control of the minor, and does not mean that the caregiver has legal custody of the minor.
A person who relies on this affidavit has no obligation to make any further inquiry or investigation.
This affidavit is valid for only one (1) year after the date on which it is executed.