San Mateo — Caregiver Authorization Affidavit

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/l-pr-4caregiver-authorization-affidavit.pdf

Caregiver’s Authorization A fidavit

Use of this a fidavit 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 a fidavit is su ficient 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 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:

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5. I am a relative of the child (see back of this form for a definition of “relative”).

6. Check one or both (for example, if one parent was advised and the other cannot be located):

   ◻ I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to authorize medical care and have received no objection.

   ◻ I am unable to contact the parent(s) or other person(s) having legal custody of the 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 or government-issued consular card number: _______________________________________

Warning to Caregiver: 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.

Warning to Local Educational Agencies and Health Care Service Providers: A seal or signature from a court is not required. This form is not required to be notarized.

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 a fect 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 a fidavit has no obligation to make any further inquiry or investigation.

Additional Information:

TO CAREGIVERS:

1. “Relative,” for purposes of item 5, means an adult who is related to the child by blood, adoption, or a finity within the fifth degree of kinship, including stepparents, stepsiblings, and all relatives whose status is preceded by the words “great,” “great-great,” or “grand,” or the spouse of any of these persons even if the marriage was terminated by death or dissolution.

2. The law may require you, if you are not a relative, or a currently licensed, certified, or approved foster parent, to obtain resource family approval pursuant to Section 1517 of the Health and Safety Code or Section 16519.5 of the Welfare and Institutions Code 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, the a fidavit is no longer valid. You are required to notify any school, health care provider, or health care service plan to which you have given this afidavit that the minor is no longer living with you and that, as a result, the a fidavit is no longer valid.

4. If you do not have the information requested in item 8 (California driver’s license or I.D., or government-issued consular card), provide another form of identification such as your social security number or Medi-Cal number.

   TO SCHOOL OFFICIALS:

5. Section 48204 of the Education Code provides that this a fidavit constitutes a su ficient 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.

6. The school district may require additional reasonable evidence that the caregiver lives at the address provided in item 4.

7. A seal or signature of the court is not required. This form is not required to be notarized.

   TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

8. When signed by a relative, this a fidavit shall confer the same rights to authorize medical care and dental care for the minor that are given to guardians under Section 2353 of the Probate Code. The medical care authorized by a relative caregiver may include mental health treatment subject to the limitations of Section 2356 of the Probate Code.

9. A health care service provider who acts in good faith reliance upon a caregiver’s authorization a fidavit to provide medical or dental care, without actual knowledge of facts contrary to those stated on the a fidavit, is not subject to criminal liability or to civil liability to any person, and is not subject to professional disciplinary action, for that reliance if the applicable portions of the form are completed. A seal or signature of the court is not required. This form is not required to be notarized.

10. This afidavit does not confer dependency for health care coverage purposes.

JURAT FORM – CAREGIVER’S AUTHORIZATION AFFIDAVIT

STATE OF CALIFORNIA )

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COUNTY OF ____________________ )

Subscribed and sworn to (or a firmed) before me on this ______ day of ____________ 20___, by ______________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

_____________________________________ NOTARY SEAL

Signature of Notary Public (Stamp seal above)

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Print Name of Notary Public

(Amended by Stats. 2025, Ch. 664, Sec. 5. (AB 495) E fective January 1, 2026.) Rev. 1.2.2026