Caregiver’s Authorization Affidavit
Use of this affidavit is authorized by Part 1.5 (commencing with §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
both enrollment of a minor in school and school-related medical care. Completion of items 5–8 is
additionally required to authorize any other medical care. Print clearly.
I am requesting enrollment of the minor in school and to authorize school-related medical
care. (Completion of items 1–4 is required only.)
I am also requesting to authorize medical care not school-related. (Completion of items 1–8
1. Name of minor:
2. Minor’s birth date:
3. My name (adult giving authorization):
4. My home address:
? I am a grandparent, aunt, uncle, or other qualified relative of the minor (see back 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 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.
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