Caregivers Authorization Affidavit PDF Details

The Caregiver's Authorization affidavit is usually signed by the child's parent or legal guardian and notarized. It gives the caregiver the authority to make decisions related to the child's education, healthcare, and other important matters. This can include giving permission for medical treatments, enrolling the child in school, and signing consent forms for activities.

This document can be helpful in situations where the child's parent or legal guardian is unable to care for the child due to illness, military deployment, or other circumstances. It can also be used when the child is staying with a caregiver for an extended period of time, such as during the summer months.

The listing includes information about the caregivers authorization affidavit. It's definitely worth making the effort to study this prior to starting filling out your form.

Form Name Caregivers Authorization Affidavit
Form Length 3 pages
Fillable? Yes
Fillable fields 6
Avg. time to fill out 2 min 1 sec
Other names caregiver affidavit form california, california courts caregivers affidavit, caregiver affidavit, caregivers affidavit ca

Form Preview 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

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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:


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.


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

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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

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How to Edit Caregivers Authorization Affidavit Online for Free

Filling out documents along with our PDF editor is more straightforward when compared with most things. To modify ca caregivers affidavit form the form, there is little you have to do - just adhere to the actions listed below:

Step 1: The webpage includes an orange button stating "Get Form Now". Press it.

Step 2: You'll notice each of the options that it's possible to undertake on the file once you've entered the ca caregivers affidavit form editing page.

In order to fill in the form, type in the details the program will require you to for each of the appropriate sections:

part 1 to filling in caregivers affidavit ca

Feel free to type in your information in the field Use of this affidavit is, and cid, 70 I have advised the.

Filling in caregivers affidavit ca stage 2

Jot down the significant particulars in California Courts Self, Help Center, and Page 1 of 3 segment.

Finishing caregivers affidavit ca stage 3

Please be sure to describe the rights and obligations of the sides inside the California Courts Self, Help Center, and Page 2 of 3 section.

Filling out caregivers affidavit ca part 4

Finish by taking a look at the next sections and filling them out as required: California Courts Self, Help Center, and Page 3 of 3.

Completing caregivers affidavit ca stage 5

Step 3: Click the Done button to be certain that your completed document is available to be exported to each device you use or mailed to an email you indicate.

Step 4: To prevent yourself from any kind of difficulties as time goes on, you should create up to several copies of your document.

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