Caregiver Information

Below you will find information explaining the role of caregivers as it pertains to enrolling students in school. The attached affidavit allows a caregiver to enroll a child in school and consent to a child’s medical care. It is important to note that the Caregiver’s Affidavit does not take away or suspend parental rights. A parent or guardian can overrule any of the Caregiver’s decisions, unless the parent or guardian’s wishes jeopardize the child’s health, life, or safety. It does not apply to Special Education services. This form complies with Family Code Section 6550. Please be advised that this form needs to be resubmitted yearly.

It is important that this form be completed in its entirety to ensure its validity. The Caregiver’s Affidavit must include :

1) Lines 1-4 completed, and a signature and date on the affidavit - This enables a Caregiver to enroll a child in school and consent to any medical care that is required for school enrollment, such as physicals and medical examinations performed on school grounds.

2) Lines 5-8 should be completed  if the caregiver is a relative of the child.  Lines 5-8 allow relative Caregivers to consent to medical, dental and mental health care.

Please note: A Caregiver’s Affidavit is a legal document. A Caregiver signs the affidavit under penalty of perjury that he or she is the child’s Caregiver and all information is true. If the child stops living with the Caregiver, the Caregiver should inform the school and all other agencies that have been given the Caregiver’s Affidavit.

Next step: Please make a copy of the completed and signed affidavit and  turn those forms into the child’s school and /or daycare provider as well as their health care provider.

There is no need to file the affidavit in court. The Affidavit is valid for one year from the date it was completed and signed. If care is required for more than one year, the Caregiver should fill out another affidavit.

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. It does not apply to Special Education services.

Instructions: Completion of items 1-4 and the signing of the affidavit authorizes the Caregiver to enroll a child in school and consent to school related medical care. Completion of items 5-8 authorizes a Relative Caregiver to consent to any other medical care.

Parents need not sign Affidavit.

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

1. My name: _________________________________  Phone:___________________.

2. My home address: ____________________________________________________.

3. Minor’s Name: _______________________________________________________.

4. Minor’s Date of Birth: __________________________________________________.

RELATIVES ONLY ITEMS 5 - 8

5. (   ) I am a grandparent, aunt, uncle, spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, niece, nephew, first cousin, or any person denoted by the prefix “grand” or “great,” or the spouse of any of the people listed above, even if that person is deceased.

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 and the United States that the foregoing is true and correct.

Signed at: _____________________________ Dated: ____________________________

Signature of Caregiver: _____________________________________________________