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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.

4. My home address: 

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

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. *
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