Santa Clara — Sample

Source: https://santaclara.courts.ca.gov/system/files/sample_caregiver_affidavit_0.pdf

Caregiver Authorization Affidavit

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 5-8 is additionally required to authorize any other medical care.

I AFFIRM THAT THE FOLLOWING INFORMATION IS TRUE AND CORRECT:

MINOR:

1. Name: ___________________________________________________________

2. Birthdate: ________________________________________________________

   CAREGIVER INFORMATION:

My name (adult giving authorization): _________________________________ My home address: _________________________________________________ _________________________________________________

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

( ) I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back of this form for a definition of "qualified relative").

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 persons(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.

My date of birth: _____________________________________________________

My California driver's license or identification care number: ___________________

WARNING: Do no 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: _________________________________

SEE NOTICES ON THE BACK OF THIS PAGE

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CAREGIVER AUTHORIZATION AFFIDAVIT

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 further inquiry or investigation.

3. This affidavit is not valid for more than one year after the date on which it was executed.

   ADDITIONAL INFORMATION:

TO CAREGIVERS:

1. "Qualified Relative", for purposes of item 5, manes 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 the minor. If you have any questions please contact your local Department of Social Services.

3. If the minor stops living with you, you are required to notify any school, health care provided, 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 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 stated 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.

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CAREGIVER AUTHORIZATION AFFIDAVIT