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The Caregiver's Authorization Affidavit form serves as a vital tool for caregivers looking to ensure that a minor receives necessary education and medical care. Designed under California law, this affidavit allows adults aged 18 and over, who live with the minor, to authorize school enrollment and medical treatments. To be effective, the caregiver must complete and sign specific sections of the form, confirming their relationship to the minor as a grandparent, aunt, uncle, or other qualified relative. If the caregiver cannot advise the parents or legal guardians, there's an option to indicate that inability. Importantly, while this affidavit allows for school attendance and medical care, it does not grant legal custody over the minor. Once executed, the affidavit is valid for one year, but caregivers are responsible for notifying relevant parties if the minor no longer lives with them. Health care providers and school officials can rely on this affidavit, as it simplifies residency and care determinations without needing additional legal documentation. Understanding the implications of this form empowers caregivers in navigating their essential role in a child's life.

Caregivers Authorization Affidavit Example

Caregiver's Authorization Affidavit

Use of this affidavit 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 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. 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 (street, apartment number, city, state, zip code):

______________________________________________

______________________________________________

______________________________________________

5.I am a grandparent, aunt, uncle, or other qualified relative of the minor (see page 2 of this form for a definition of "qualified 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's driver's license or 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 laws of the State of California that the foregoing is true and correct.

Dated: _____________________ Signed: ________________________

California Courts Self-Help Center

Page 1 of 3

www.courtinfo.ca.gov/selfhelp/

 

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 any further inquiry or investigation.

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

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, you 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.

California Courts Self-Help Center

Page 2 of 3

www.courtinfo.ca.gov/selfhelp/

 

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 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.

California Courts Self-Help Center

Page 3 of 3

www.courtinfo.ca.gov/selfhelp/

 
Get Caregivers Authorization Affidavit PDF Form

Form Characteristics

Fact Name Details
Governing Law Authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code.
Purpose This affidavit allows a caregiver to enroll a minor in school and authorize school-related medical care.
Eligibility The caregiver must be an adult (18 years or older) and must be a qualified relative of the minor.
Validity Duration The affidavit is only valid for one year after it is signed.
Liability Protection Healthcare providers relying on this affidavit are protected from liability if they act in good faith.

Guidelines on Utilizing Caregivers Authorization Affidavit

When preparing to fill out the Caregiver's Authorization Affidavit, it’s important to understand that this process facilitates the enrollment of a minor in school and allows for school-related medical care. Follow the steps below to complete the form correctly.

  1. Start by printing the form clearly, as legibility is crucial.
  2. Fill in the name of the minor in the designated space.
  3. Next, enter the minor's birth date.
  4. Provide your name as the adult giving the authorization.
  5. Complete your home address, including street, apartment number (if applicable), city, state, and zip code.
  6. Indicate your relationship to the minor, choosing from options such as grandparent, aunt, uncle, or another qualified relative.
  7. Check the appropriate box to confirm whether you have advised the parent(s) or legal guardians of your intent to authorize medical care, or if you are unable to contact them.
  8. Fill in your date of birth to verify your age.
  9. Provide either your California driver's license number or your identification card number. If you do not have either, you may supply another form of identification, like your social security number.
  10. Review all entries to ensure accuracy before signing the form.
  11. Finally, date the form and sign it to affirm the information is correct under penalty of perjury.

Completing this form accurately is an essential step in ensuring that the minor can access school and medical services without delay. Once you have filled out the form and signed it, you can present it to the relevant schools or healthcare providers as needed.

What You Should Know About This Form

What is the purpose of the Caregiver's Authorization Affidavit?

The Caregiver's Authorization Affidavit allows a caregiver to enroll a minor in school and authorize school-related medical care. It is especially useful for family members like grandparents, aunts, or uncles who may be responsible for the minor but do not have legal custody. By completing this affidavit, caregivers can act in the best interest of the child, ensuring they receive necessary educational and medical services without undue delay.

Who qualifies as a "qualified relative" under this affidavit?

A "qualified relative" includes anyone in the family tree. This encompasses grandparents, aunts, uncles, and even siblings. Specifically, it includes spouses, stepparents, half-siblings, cousins, and others denoted by "grand" or "great." Understanding this definition helps caregivers know if they can provide authorization for a minor.

Do I need to contact the minor's parents before I complete this affidavit?

If possible, it's recommended to notify the minor's parents or legal guardians of your intent to authorize medical care. You should check one of the options in the affidavit to indicate whether you've advised them or if you were unable to contact them. This approach fosters communication and ensures that you are acting responsibly in the interests of the child.

How long is the Caregiver’s Authorization Affidavit valid?

This affidavit remains valid for up to one year from the date it is signed. Renewing your authorization is essential if providing care continues beyond that period. Doing so keeps the welfare of the minor up to date and compliant with legal requirements.

What should I do if the minor stops living with me?

If the minor no longer resides in your home, it’s important to inform any schools, healthcare providers, or health care service plans that received the affidavit. This notification will update them on the minor's living situation, preventing potential issues related to unauthorized medical or educational decisions.

Common mistakes

Filling out the Caregivers Authorization Affidavit form can be a straightforward process, but mistakes can often lead to complications. One common error occurs in the completeness of the information provided. Applicants sometimes skip important fields or leave them blank, such as the minor’s date of birth or the caregiver’s home address. Omitting this information may invalidate the affidavit, causing delays and requiring the form to be filled out again.

Another frequent mistake involves misunderstanding the definition of a "qualified relative". Caregivers may mistakenly believe that anyone close to the minor qualifies, when, in fact, the law has specific criteria. Failing to accurately identify the relationship can result in complications when seeking authorization for medical care or school enrollment, creating hurdles that could have easily been avoided with a clear understanding of the requirements.

Moreover, the failure to notify the legal guardians can create significant issues. The affidavit requires caregivers to either inform the minor’s parent(s) or to note that they could not be contacted. Some caregivers overlook this requirement, thinking that their authorization will automatically cover any potential objections. This oversight not only undermines the legal standing of the affidavit but may also strain relationships with the child’s family.

Finally, caregivers sometimes neglect to double-check the accuracy of their declarations. Signing under penalty of perjury means you are verifying that all the information is true and correct. Ambiguities or inaccuracies, whether intentional or accidental, can lead to serious legal ramifications. Ensuring that each statement is both honest and precise is vital for maintaining the integrity of the affidavit.

Documents used along the form

The Caregiver's Authorization Affidavit form is an essential document for caregivers who are responsible for the care of a minor. Several other forms and documents may accompany this affidavit to ensure that all legal and medical needs are met for the child. Below is a list of such documents commonly used alongside the Caregiver's Authorization Affidavit.

  • Health Care Proxy: This document allows an individual to designate someone else to make health care decisions on their behalf. It ensures that a caregiver has the authority to make medical decisions in the best interest of the minor if necessary.
  • Educational Authorization Form: This form grants permission for a caregiver to act on behalf of a minor in educational settings. It is commonly required for enrollment, school-related activities, and accessing academic records.
  • Medical Consent Form: This document provides explicit permission for the caregiver to authorize medical treatment for the minor. It may include details about specific medical care or procedures the caregiver can approve.
  • Emergency Medical Information Form: This form contains essential information about the minor’s medical history, allergies, and emergency contacts. It can be crucial in urgent medical situations.
  • Temporary Guardianship Agreement: This legal document outlines the temporary guardianship of a child, detailing the duration and responsibilities. It provides a formal framework in situations where long-term arrangements are not immediately possible.
  • Identification Documents: Forms of identification, such as a driver's license or state ID, are necessary to confirm the identity of the caregiver. This verification helps ensure proper authorization and care for the minor.

These documents collectively enhance the caregiver's ability to provide for the minor's needs while ensuring compliance with legal requirements. Properly completed forms help streamline processes related to health care, education, and legal matters surrounding the well-being of the child.

Similar forms

The Caregivers Authorization Affidavit serves an important function in managing the care and education of minors. It has similarities to several other legal documents designed for similar purposes. Here are six documents with which the Caregivers Authorization Affidavit is similar:

  • Power of Attorney for Minor Children: This document allows a parent or legal guardian to delegate their authority to a specified caregiver, enabling that individual to make decisions regarding the child's welfare, including medical care and education.
  • School Enrollment Affidavit: This form verifies a student's residency when enrolling in school. It requires the individual providing care to confirm their address and the child's residence, similar to the caregiver’s responsibility outlined in the affidavit.
  • Authorization for Medical Treatment: Commonly used in healthcare settings, this document gives medical professionals permission to provide care to a child. Like the affidavit, that form is aimed at ensuring minors receive necessary medical assistance when parents or guardians are not present.
  • Foster Care Application: This document is used to apply for a license to care for children in a foster setting. It contains similar requirements for background checks and home assessments, paralleling some obligations found in the caregivers affidavit.
  • Emergency Contact Form: Often used in schools and healthcare facilities, this document lists individuals authorized to make decisions for a child in emergencies. Both documents ensure a child's care is prioritized while clarifying who has the authority to act on the child’s behalf.
  • Custody Agreement: This legally binding agreement outlines the rights and responsibilities of parents or guardians regarding their child's care. Like the affidavit, it highlights the importance of securing the well-being of the child in a structured format.

Dos and Don'ts

When filling out the Caregiver's Authorization Affidavit form, it’s important to approach the task methodically. The following list outlines key do’s and don’ts to ensure a smooth process.

  • Do complete items 1 to 4 to authorize enrollment of the minor in school.
  • Do provide clear and accurate information. Ensure that all names and dates are correct.
  • Do sign and date the affidavit after confirming that all information is true.
  • Do keep a copy of the completed affidavit for your records.
  • Do inform the relevant school or healthcare providers if the minor will no longer reside with you.
  • Don't sign the form if any of the information provided is incorrect; doing so could lead to legal consequences.
  • Don't forget to complete items 5 to 8 if you wish to authorize medical care beyond school-related services.
  • Don't use a form of identification other than what is required in item 8 unless explicitly stated.
  • Don't assume that this affidavit grants you legal custody of the minor; it does not.
  • Don't neglect to notify the minor’s parents or legal guardians of your intent to authorize medical care when appropriate.

Misconceptions

Understanding the Caregivers Authorization Affidavit is crucial for caregivers. Here are eight misconceptions that often arise:

  • This form grants legal custody of the minor. The affidavit does not transfer legal custody; parents retain their rights regarding care and control.
  • Only family members can use this affidavit. While relatives are preferred, non-relatives can obtain a foster home license to care for the minor.
  • It is valid indefinitely. The affidavit is only valid for one year from the date it is signed.
  • Completion of all sections is always necessary. For school enrollment and school-related medical care, only items 1-4 need to be completed.
  • No notification to parents is needed. The caregiver must inform the parents or legal guardians of their intent to authorize medical care, unless they cannot be contacted.
  • The affidavit cannot be used for school enrollment. The affidavit is a sufficient basis for establishing residency for school without needing additional custody documentation.
  • All identification requirements can be ignored. If lacking a driver’s license or ID, another form of identification must be provided.
  • Health care providers have no obligations. Providers acting in good faith upon reliance of the affidavit are safeguarded against liability but must follow the law.

Being well-informed ensures that caregivers can navigate this process effectively and provide the necessary support for the minors in their care.

Key takeaways

Here are some key takeaways regarding the Caregiver's Authorization Affidavit form:

  1. Purpose: This affidavit allows a caregiver to enroll a minor in school and authorize school-related medical care, provided parts 1-4 are completed.
  2. Additional Medical Care: To authorize other medical care, you must complete items 5-8 in addition to the first four.
  3. Print Clearly: It's essential to fill out the form legibly to avoid misunderstandings.
  4. Age Requirement: The caregiver must be at least 18 years old.
  5. Qualified Relative: The term "qualified relative" includes various family members, such as grandparents, aunts, and uncles.
  6. Parental Notification: You must inform the minor's parent(s) or legal guardians of your intention to authorize medical care, unless you cannot reach them.
  7. Term of Validity: This affidavit is only valid for one year from the date it is signed.
  8. Legal Implications: Providing false information can lead to serious legal consequences.
  9. Residency Determination: Schools can use this affidavit to establish the residency of the minor without needing a guardianship order.
  10. Notification of Changes: If the minor moves out of your home, you must inform any schools or healthcare providers that have this affidavit.

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