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 (street, apartment number, city, state, zip code):
______________________________________________
______________________________________________
______________________________________________
5. F 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):
F 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.
F 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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JUDICIAL SUBPOENA
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Courtat thethe Honorable
located at
County of
o'clock in theday of noon, and at any recessedin room , on the , 20 , at
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
I
Calendar No.
THE PEOPLE OF THE STATE OF NEW YORK
TO
Index No.
,
American LegalNet, Inc.
www.USCourtForms.com
Court in
Witness, Honorable , one of the Justices of the
day of , 20County,
COURT
COUNTY OF
Plaintiff(s)
-against-
Defendant(s)
:
:
:
:
:
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Mobile Tel. No.:
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, 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.
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.
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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.