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Caregiver Authorization Affidavit Template
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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): ___________________
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Caregiver Authorization Affidavit Template
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For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
CAREGIVER AUTHORIZATION AFFIDAVIT TEMPLATE FAQ
What is a caregiver authorization affidavit?
A Caregiver Authorization Affidavit is a sworn document in which a parent or legal guardian authorizes another adult (the caregiver) to care for a minor child and handle certain day-to-day needs — such as school enrollment, obtaining school records, and coordinating routine medical care. It is often used when a child is staying with a relative or trusted adult temporarily.
Is this the same as guardianship or a power of attorney?
Not necessarily. This affidavit usually grants limited, temporary authority and may not transfer legal custody. Some states have specific caregiver affidavit forms and rules. If you need broader authority (or long-term custody changes), a guardianship or minor power of attorney may be more appropriate.
What should be included?
Include: child information, parent/guardian information, caregiver details, the authority granted, any limits, start and end dates, and emergency contact information. This template includes optional sections for school and medical authorization.
Do you need notarization?
Often yes, especially for school or medical use. Some jurisdictions require witnesses or specific language. This template includes notarization and an optional witness section.
How long does it last?
It depends on your needs and local rules. This template includes an expiration date and a revocation option so you can set a clear timeframe.
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