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The Caregivers Authorization Affidavit is an essential document for anyone stepping in to care for a minor in California. This form allows caregivers, such as grandparents or other qualified relatives, to authorize a child's enrollment in school and to consent to school-related medical care. To complete the affidavit, caregivers must fill out specific sections, including details about the minor and their relationship to them. If the caregiver intends to authorize additional medical care, further information is required. It's crucial to understand that while this affidavit grants certain rights, it does not affect the legal custody of the minor's parents or guardians. The affidavit remains valid for one year and must be signed under penalty of perjury, ensuring the information provided is accurate. Caregivers must also be aware of their responsibilities, such as notifying schools and healthcare providers if the minor no longer resides with them. Understanding the nuances of this form is vital for ensuring that caregivers can effectively support the minors in their care.
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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
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 (street, apartment number, city, state, zip code):
______________________________________________
______________________________________________
______________________________________________
5.I am a grandparent, aunt, uncle, or other qualified relative of the minor (see page 2 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's 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: ________________________
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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.
Additional Information:
TO CAREGIVERS:
1."Qualified relative," for purposes of item 5, means a spouse, parent, stepparent, brother, sister, stepbrother, stepsister,
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.
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
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.
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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 stated 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.
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Form Specifications
| Fact Name | Fact Details |
|---|---|
| Governing Law | This affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California Family Code. |
| Purpose | It allows a caregiver to enroll a minor in school and authorize school-related medical care. |
| Additional Medical Care | Items 5-8 must be completed to authorize any medical care beyond school-related needs. |
| Age Requirement | The caregiver must be 18 years of age or older. |
| Minor's Information | The form requires the name and birth date of the minor being cared for. |
| Qualified Relative | A caregiver must be a grandparent, aunt, uncle, or other qualified relative to complete the form. |
| Notification Requirement | The caregiver must inform the minor's parents or legal guardians of their intent to authorize medical care. |
| Validity Period | This affidavit is only valid for one year from the date it is signed. |
| Legal Rights | It does not affect the legal rights of the minor's parents or guardians regarding custody. |
| Reliance Protection | Individuals acting in good faith based on this affidavit are protected from criminal and civil liability. |
Caregivers Authorization Affidavit: Usage Guidelines
Completing the Caregiver's Authorization Affidavit form is an important step in ensuring that a minor can receive necessary medical care and enroll in school. The following instructions will guide you through the process of filling out the form accurately and effectively.
- Gather necessary information: Before starting, collect the required details about the minor and yourself.
- Fill in the minor's name: In the first blank, write the full name of the minor.
- Enter the minor's birth date: In the second blank, provide the minor's date of birth.
- Provide your name: In the third blank, write your full name as the adult giving authorization.
- Complete your address: In the fourth blank, fill in your complete home address, including street, apartment number, city, state, and zip code.
- Indicate your relationship: In the fifth item, check the appropriate box to confirm your relationship to the minor (e.g., grandparent, aunt, uncle, etc.).
- Notify the parents or legal guardians: In the sixth item, check one or both boxes to indicate whether you have advised the parents or legal guardians of your intent to authorize medical care.
- Provide your date of birth: In the seventh blank, enter your date of birth.
- Input your identification number: In the eighth blank, write your California driver's license or identification card number. If you do not have this, provide an alternative form of identification.
- Sign and date the affidavit: At the bottom of the form, sign your name and date the document.
Once you have completed the form, ensure that all information is accurate before submitting it. Keep a copy for your records. This form will help facilitate the enrollment of the minor in school and ensure they receive necessary medical care.
Your Questions, Answered
What is a Caregiver's Authorization Affidavit?
The Caregiver's Authorization Affidavit is a legal document in California that allows a caregiver to enroll a minor in school and authorize school-related medical care. This affidavit can also be used to grant permission for other medical care, provided additional sections are completed. It is designed to simplify the process for caregivers who are responsible for a child but do not have legal custody.
Who can use this affidavit?
Any adult who is 18 years of age or older and lives with the minor can use this affidavit. The caregiver must be a qualified relative, which includes grandparents, aunts, uncles, and other specified relatives. It is important to ensure that the caregiver has the authority to act on behalf of the minor.
What information do I need to provide?
You will need to fill out several items, including the name and birth date of the minor, your name and address, and your relationship to the minor. Additionally, you will need to confirm whether you have notified the minor's parents or legal guardians about your intent to authorize medical care.
Is this affidavit valid for a long time?
No, the Caregiver's Authorization Affidavit is only valid for one year from the date it is signed. After that period, a new affidavit must be completed to continue the authorization for medical care and school enrollment.
What happens if the minor no longer lives with me?
If the minor stops living with you, it is your responsibility to inform any school, health care provider, or health care service plan to which you have given the affidavit. This ensures that all parties are aware of the change in living arrangements and can update their records accordingly.
Can I authorize medical care for the minor without notifying the parents?
You can authorize medical care without notifying the parents only if you are unable to contact them. If you have contacted them and received no objections, you can proceed. It is crucial to follow the correct procedure to avoid any legal issues.
What if I don’t have a California driver's license or ID?
If you do not have a California driver's license or identification card, you can provide an alternative form of identification, such as your social security number or Medi-Cal number. This information helps to verify your identity as the caregiver.
Does this affidavit give me legal custody of the minor?
No, signing this affidavit does not grant you legal custody of the minor. The rights of the minor's parents or legal guardians remain intact. This document simply allows you to make decisions regarding the minor's education and medical care.
Common mistakes
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Incomplete Information: Failing to fill out all required fields, such as the minor's name or birth date, can render the affidavit invalid. Ensure that items 1 through 4 are fully completed before signing.
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Incorrect Signatures: The affidavit must be signed by the adult giving authorization. If someone else signs it, it may not be accepted.
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Failure to Notify Parents: Not advising the minor's parents or legal guardians of the intent to authorize medical care can lead to complications. Make sure to check the appropriate box regarding notification.
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Misunderstanding "Qualified Relative": Some people may not fully understand who qualifies as a "qualified relative." Be sure to review the definition provided in the form to ensure eligibility.
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Missing Identification: Item 8 requires a California driver's license or ID number. If you don’t have one, be sure to provide an alternative form of identification as stated in the instructions.
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Ignoring the One-Year Validity: This affidavit is only valid for one year from the date it is signed. Failing to renew it can lead to issues in medical or educational settings.
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Not Updating Information: If the minor stops living with you, it’s essential to notify any schools or healthcare providers. Failing to do so can cause confusion and potential legal issues.
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Signing Under False Pretenses: Signing the affidavit when any of the statements are incorrect is a serious offense. Always ensure that all information provided is true and accurate.
Documents used along the form
The Caregivers Authorization Affidavit is an important document that allows caregivers to enroll a minor in school and authorize medical care. However, there are several other forms and documents that may be required or helpful in conjunction with this affidavit. Understanding these documents can help ensure that caregivers have all necessary permissions and information at hand.
- Power of Attorney for Minor Child: This document grants a designated person the authority to make decisions on behalf of a minor, particularly in legal, medical, or educational matters. It is essential for caregivers who may need to act in the absence of the child's parents.
- Medical Consent Form: This form allows caregivers to provide consent for medical treatment on behalf of a minor. It is particularly useful for routine medical visits or emergencies when parents are unavailable.
- School Enrollment Form: Required by schools for enrolling a minor, this form collects information about the child and their guardians. It often requires proof of residency and may need to be submitted alongside the Caregivers Authorization Affidavit.
- Emergency Contact Form: This document lists individuals who can be contacted in case of an emergency involving the minor. It is crucial for caregivers to ensure that schools and healthcare providers have this information readily available.
- Proof of Residency: Caregivers may need to provide documentation to verify their address. This could include utility bills, lease agreements, or other official documents that confirm the caregiver's residence.
- Foster Care License: If the caregiver is not a relative, they may need to obtain a foster care license. This document certifies that the caregiver meets state requirements to provide care for minors.
- Child Medical History Form: This form provides healthcare providers with essential information about the minor's medical history, allergies, and previous treatments. It is vital for ensuring appropriate medical care.
- Behavioral Health Consent Form: If the minor requires mental health services, this document allows caregivers to consent to treatment. It is important for accessing necessary psychological support.
- Authorization for Release of Information: This form permits the sharing of the minor's medical or educational records with specific individuals or organizations. It can facilitate communication between caregivers, schools, and healthcare providers.
Having these documents prepared can help caregivers navigate the responsibilities associated with caring for a minor. By ensuring all necessary forms are in order, caregivers can provide a stable and supportive environment for the child in their care.
Similar forms
- Power of Attorney for Health Care: This document allows an individual to appoint someone else to make medical decisions on their behalf. Like the Caregiver's Authorization Affidavit, it grants authority for medical care but is typically broader in scope, covering all health-related decisions rather than just those for a minor.
- Temporary Guardianship Agreement: This form allows a caregiver to take temporary custody of a child. It is similar to the Caregiver's Authorization Affidavit in that it provides legal authority for the caregiver to make decisions for the minor, but it usually involves a more formal arrangement and may require court approval.
- Consent to Treat a Minor: This document is used by parents or legal guardians to authorize medical treatment for their child. It shares similarities with the Caregiver's Authorization Affidavit, as both forms aim to ensure that a caregiver can make medical decisions for a minor in the absence of a parent.
- School Enrollment Form: This form is used to enroll a child in school and may require proof of residency and guardianship. The Caregiver's Authorization Affidavit serves a similar purpose by establishing that the caregiver has the authority to enroll the minor in school and make related decisions.
Dos and Don'ts
When filling out the Caregiver's Authorization Affidavit form, it is important to follow specific guidelines to ensure accuracy and compliance. Here are five things you should and shouldn't do:
- Do print clearly. Legible handwriting is essential for all information provided.
- Do ensure all required fields are completed. Items 1-4 are necessary for school enrollment and medical care authorization.
- Do verify your relationship to the minor. Confirm that you qualify as a relative as defined in the instructions.
- Don't sign the affidavit if any information is incorrect. Doing so may lead to legal consequences.
- Don't forget to notify relevant parties if the minor no longer lives with you. This includes schools and healthcare providers.
By adhering to these guidelines, you can ensure that the affidavit is completed correctly and serves its intended purpose.
Misconceptions
Understanding the Caregiver's Authorization Affidavit can be challenging, and there are several misconceptions that often arise. Here are seven common misunderstandings:
- It grants legal custody to the caregiver. This affidavit does not give the caregiver legal custody of the minor. The rights of the minor's parents or legal guardians remain intact.
- All caregivers can use this form. Only qualified relatives, such as grandparents, aunts, or uncles, can complete this affidavit. Non-relatives may need a foster home license.
- It is valid indefinitely. The affidavit is only valid for one year from the date it is signed. After that, a new affidavit must be completed.
- Signing requires both parents' consent. While it's best practice to inform the minor's parents or legal guardians, the caregiver can still sign if they cannot be contacted.
- Caregivers can authorize any type of medical care. To authorize medical care beyond school-related services, additional items on the form must be completed.
- Providing a Social Security number is sufficient. If a California driver's license or identification card number is not available, other forms of ID may be required, but a Social Security number alone may not suffice.
- Schools must accept the affidavit without question. While the affidavit serves as proof of residency, schools may still require additional evidence to verify the caregiver's address.
By clearing up these misconceptions, caregivers can better navigate the process and ensure they are meeting all necessary requirements.
Key takeaways
Filling out the Caregivers Authorization Affidavit form is an important step for caregivers. Here are some key takeaways to keep in mind:
- Understand the Purpose: This form allows caregivers to enroll a minor in school and authorize school-related medical care.
- Complete Required Sections: Fill out items 1-4 to authorize school enrollment and medical care. Items 5-8 are needed for additional medical care.
- Eligibility: Ensure you qualify as a caregiver, such as being a grandparent, aunt, uncle, or another qualified relative.
- Notification of Parents: You must inform the minor's parents or legal guardians about your intent to authorize medical care, unless you cannot contact them.
- Validity: The affidavit is valid for only one year from the date it is signed.
- Legal Custody: Signing this affidavit does not grant you legal custody of the minor. Parents retain their rights regarding care and custody.
- Notify Changes: If the minor stops living with you, notify any relevant schools or healthcare providers.
- Identification: If you lack a California driver's license or ID, provide an alternative form of identification, like your social security number.
By understanding these points, caregivers can effectively use the Caregivers Authorization Affidavit form to ensure the well-being of the minor in their care.