COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : : Index No. Calendar No. SUPERIOR COURT OF CALIFORNIA - COUNTY OF SAN MATEO CAREGIVER AUTHORIZATION AFFIDAVIT Plaintiff(s) JUDICIAL SUBPOENA Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the -against: 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: TO Defendant(s) : ...................................................... : _______________________________________________________________ _______________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK 3. My name (adult giving authorization): _____________________________________________________ 4. My home address: GREETINGS: the Honorable ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before at the Court , 5. ICounty of am a grandparent, aunt, uncle, located atqualified relative of the minor (see page 2 of this form for a or other definition of a "qualified relative"). in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 6. Check one or both (for example, if one parent was advised and the other cannot be located): [ [ 7. 8. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to my intent to authorize medical issued for a maximum penalty of $50 the party on whose behalf this subpoena wascare, and have received no objection.and all damages sustained as a result of your failure to comply. ] I have advised the parent(s) or other person(s) having legal custody of the minor of ] 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. , one of the Justices of the Witness, Honorable County, day of , 20 Court in My date of birth: _______________________________________________________________. ___________________________ (Attorney must sign above and type name below) My California's driver 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 Attorney(s) for 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. Office and P.O. Address Dated:____________________________ Notices: Page 1 of 2 PR-4 [Rev.3/04] Signed: ______________________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: www.sanmateocourt.org American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. SUPERIOR COURT OF CALIFORNIA - COUNTY OF SAN MATEO 1. This declaration does not affect the rights of the minor's parents or legal guardian regarding the care, : JUDICIAL SUBPOENA Plaintiff(s) custody, and control of the minor, and does not mean that the caregiver has legal custody of the minor. -against: 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:. . . . . . . . . . . . . . . . . . . .Defendant(s) . . . . . . . ................. .......... TO CAREGIVERS: THE PEOPLE relative," for OF NEW of item 1. "Qualified OF THE STATEpurposes YORK 5, means a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person TOdenoted 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 GREETINGS: foster home license in order to care for a minor. If you have any questions, please contact your local department of social services. all business and excuses being laid aside, you and each of you attend before WE COMMAND YOU, that 3. If the minor stops living with you, you are required to notify any school, health care provider, or health located at County of care service plan to which you of given this affidavit. in room , on the day have , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the the Honorable at the Court , 4. If you do not have the information request in item 8 (California driver's license of I.D.), provide another form of identification such as your social security number or Medi-Cal number. TO SCHOOL OFFICIALS: this subpoena was issued for a maximum penalty of $50 and all damages sustained as a the party on whose behalf 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 of the Justices of the guardianship or other custody Witness, Honorable one order, unless the school district determines from actual facts that the minor is not living with the Court in County, day of , 20 caregiver. 2. The school district may require additional reasonable evidence that the caregiver lives at the address (Attorney must sign above and type name below) provided in item 4. TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS: Attorney(s) for result of your failure to comply. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 1. No person who acts in good faith reliance upon a caregiver's authorization affidavit to provide medical or dental care, without a