Caregiver's Authorization Affidavit (Pursuant to Family Code Section 6550-6552) Forms Packet Cost: $5.00 · If you feel you need legal advice or assistance before completing this affidavit, we recommend that you consult with an attorney · The Family Law Facilitator cannot assist you with the affidavit. · You must decide if the affidavit is appropriate for what you are trying to accomplish. · The affidavit is not filed with the Court and is made available to Court customers solely as a courtesy. · From Family Code Section 6550(a): School and School-Related Medical Care: A caregiver's authorization affidavit authorizes a caregiver who is 18 years of age or older and who completes items 1 through 4 of the attached affidavit to enroll a minor in school and consent to schoolrelated medical care on behalf of the minor. Medical and Dental Care: A caregiver who is a relative and who completes items 1 through 8 of the attached affidavit shall have the same rights to authorized medical and dental care for the minor that are given to guardians under Probate Code Section 2353. · A copy of Family Code Sections 6550-6552 is attached for your convenience. Yuba County Superior Court 11/12/09 Caregiver's Authorization Affidavit FL09069 American LegalNet, Inc. www.FormsWorkFlow.com 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: 5. I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back 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 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: American LegalNet, Inc. www.FormsWorkFlow.com NOTICES 1. This affidavit 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. 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. The affidavit is invalid after the school, health care provider, or health care service plan receives notice that the minor no longer lives with you. 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. A 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 not subject to criminal liability or to civil liability to any person, and is not subject to professional disciplinary action, for that reliance if the applicable portions of the form are completed. 2. This affidavit does not confer dependency for health care coverage purposes. American LegalNet, Inc. www.FormsWorkFlow.com