PR-E-LP-023 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 through 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. 2. 3. Name of minor: ______________________________________________________________ Minor’s birth date: ____________________________________________________________ My name: __________________________________________________________________ 4. My home address: __________________________________________________________ __________________________________________________________ [ ] I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back of this (adult giving authorization) 5. 6. 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 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. My date of birth: _____________________________________________________________ My California driver’s license or identification card number: ___________________________ [ ] 7. 8. 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: _________________________________________ 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. PR-E-LP-023 (Revised October 11, 2011) CAREGIVER’S AUTHORIZATION AFFIDAVIT Page 1 of 2 www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com PR-E-LP-023 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, your 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. 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 dated 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. PR-E-LP-023 (Revised October 11, 2011) CAREGIVER’S AUTHORIZATION AFFIDAVIT Page 2 of 2 www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com