CAL. FAM. CODE § 6552 : California Code - Section 6552

The caregiver's authorization affidavit shall be in substantially the following form:

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.

Instructions: Completion of items 1-4 and the

signing of the affidavit is sufficient to

authorize enrollment of a minor in school and

authorize school-related medical care.

Completion of items 5-8 is additionally

required to authorize any other medical care.

Print clearly.

The minor named below lives in my home and I

am 18 years of age or older.

1. Name of minor: ____________________________.

2. Minor's birth date: _______________________.

3. My name (adult giving authorization): _____.

4. My home address: ___________________________

______________________________________________.

_______________________________________________

5. ( ) 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.

Dated: _________________ Signed: _________________ Notices: