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Enter the full legal name of this person as it would appear on a legal document.
Enter the full legal name of this person as it would appear on a legal document.
A Caregiver Authorization Affidavit (also called a Caregiver Affidavit or Relative Caregiver Authorization) is the sworn legal document by which a parent or legal guardian authorizes a non-parent caregiver — typically a grandparent, aunt, uncle, or other trusted adult — to exercise specified parental rights on behalf of a child, including school enrollment, medical treatment, and other day-to-day decisions. Many states have adopted statutory caregiver authorization affidavit forms that schools and medical providers are legally required to accept. Unlike a formal guardianship proceeding, a caregiver authorization does not require a court order but is limited in scope and may be revoked by the parent at any time. Fill out this free caregiver authorization affidavit template online, e-sign it digitally, and download a legally valid PDF. no account or lawyer needed. Sections: Parties and Child.
State of ______________ I, ______________, declare under penalty of perjury that the following is true and correct:
Name: ______________ Address: ______________ Phone: ______________
Child's Full Name: ______________ Date of Birth: ______________ Relationship to Me: ______________ I am the parent and/or legal guardian of the above-named child and have the legal right to authorize this caregiver arrangement.
Caregiver's Name: ______________ Address: ______________ Relationship to Child: ______________ ______________ currently resides with the caregiver named above.
This Authorization is effective from ______________ through ______________, unless earlier revoked in writing by me.
I hereby authorize ______________ to act on my behalf with respect to ______________ in the following matters: ______________.
The following rights are NOT granted by this affidavit and remain solely with me as the parent/guardian: All rights not expressly granted above are retained by the parent/guardian.
This Authorization may be revoked by me at any time by providing written notice to the caregiver and to any institution (school, healthcare provider) that has received a copy of this Authorization. Revocation is effective upon delivery of written notice.
A school or health care provider that acts in good faith reliance on this authorization is not subject to civil or criminal liability. This Authorization does not affect the rights of the child's parents or legal guardian regarding the care, custody, and control of the child.
I declare under penalty of perjury under the laws of the State of ______________ that the foregoing is true and correct.
Parent / Legal Guardian Signature: ______________________________ ______________ Date: ____________________
NOTARY ACKNOWLEDGMENT State of ______________ — County of ____________________ Subscribed and sworn before me this _____ day of ______________________, 20_____. ______________________________ Notary Public My Commission Expires: ____________________ [SEAL]