Caregiver Authorization Affidavit Template

This Caregiver Authorization Affidavit (the “Affidavit”) is made on [Date] by:

Parent/Legal Guardian 1: [Full Name], address: [Address], phone/email: [Contact].
Parent/Legal Guardian 2 (Optional): [Full Name], address: [Address], phone/email: [Contact].

Caregiver: [Full Name], date of birth (optional): [DOB], address: [Address], phone/email: [Contact].
Relationship to Child: ☐ grandparent ☐ aunt/uncle ☐ adult sibling ☐ family friend ☐ other: [Explain]

Child: [Full Legal Name], date of birth: [DOB].

1. Purpose

1.1 I/we authorize the caregiver named above to provide care and supervision for the child listed above for the period and scope stated in this Affidavit.

2. Term

2.1 Start Date: [Start Date]
2.2 End/Expiration Date: [End Date]
2.3 Temporary Living Address (If Different): [Address where child will reside].

3. Authority Granted (Select All That Apply)

3.1 The caregiver is authorized to:
☐ Provide day-to-day care and supervision
☐ Sign school forms, enroll the child, and obtain school records
☐ Consent to routine medical, dental, and mental health care
☐ Obtain prescriptions and coordinate treatment
☐ Participate in school meetings and access educational information
☐ Arrange extracurricular activities and transportation
☐ Other: [List]

3.2 Limits (Optional): The caregiver may not: [List any limits].

4. Medical Information (Optional)

4.1 Child’s Primary Doctor/Clinic: [Name/Phone]
4.2 Health Insurance: [Provider/Policy]
4.3 Allergies/Conditions: [List]
4.4 Medications: [List]

5. Emergency Authorization

5.1 In an emergency, the caregiver may authorize emergency medical treatment if a parent/guardian cannot be reached promptly, subject to applicable law and provider policy.
5.2 Emergency Contacts:

• Parent/Guardian: [Name], [Phone]

• Alternate contact: [Name], [Phone]

6. Parent/Guardian Statements

6.1 I/we are the child’s legal parent(s)/guardian(s) and have authority to grant this authorization.
6.2 This authorization does not transfer legal custody and may be revoked in writing (unless prohibited by law).

7. Supporting Documents (Optional)

7.1 ☐ Copy of parent/guardian photo ID
7.2 ☐ Child’s birth certificate (copy)
7.3 ☐ Insurance card (copy)
7.4 ☐ Other: [List]

8. Statement Under Oath

8.1 I/we declare under penalty of perjury that the statements in this Affidavit are true and correct to the best of my/our knowledge.

Signatures

Parent/Legal Guardian 1: [Full Name]
Date: [Date]
Signature: ___________________________

Parent/Legal Guardian 2 (Optional): [Full Name]
Date: [Date]
Signature: ___________________________

Caregiver Acknowledgment (Optional):
I, [Caregiver Full Name], acknowledge I accept the responsibilities described in this Affidavit.

Caregiver Signature: ___________________________
Date: [Date]

Witnesses (If Required)

Witness Name: [Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (If Required)

State of [State]
County of [County]

On [Date], before me, [Notary Name], personally appeared [Parent/Guardian Name(s)] and/or [Caregiver Name] (if required), known to me (or satisfactorily proven) to be the persons whose names are subscribed to this Affidavit, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________