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State-Required 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 are 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.

The minor named below lives in my home and I am 18 years of age or older.

1. Name of Minor:*

Answer Required

2. Minor’s birth date: *

Answer Required

3. My name (adult giving authorization):*

Answer Required

4. My home address:

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

5. I am a grandparent, aunt, uncle, or other qualified relative of the minor.

Answer Required

Yes

6. I have advised the parent(s) or other persons(s) having legal custody of the minor of my intent to authorize medical care, and have received no objection.

Answer Required

Yes

7. My date of birth:*

Answer Required

8. My California Driver’s License or Identification Card Number:*

Answer Required

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. *

Answer Required

Yes

Full Name:*

Answer Required

Date:*

Answer Required