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

Notices:

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 who relies on this affidavit has no obligation to make any further inquiry or investigation.

Additional Information:

TO CAREGIVERS:

1.“Relative,” for purposes of item 5, means an adult who is related to the child by blood, adoption, or affinity within the fifth degree of kinship, including stepparents, stepsiblings, and all relatives whose status is preceded by the words “great,” “great-great,” or “grand,” or the spouse of any of these persons even if the marriage was terminated by death or dissolution.

2.The law may require you,

if you are not a relative, or a currently licensed, certified, or approved foster parent, to obtain resource family approval pursuant to Section 1517 of the Health and Safety Code or Section 16519.5 of the Welfare and Institutions Code in order to care for a minor. If you have any questions, please contact your local department of social services.

3.If the minor stops living with you, the affidavit is no longer valid. You are required to notify any school, health care provider, or health care service plan to which you have given this affidavit that the minor is no longer living with you and that, as a result, the affidavit is no longer valid.

4.If you do not have the information requested in item 8 (California driver’s license or I.D., or government-issued consular card), provide another form of identification such as your social security number or Medi-Cal number.

TO SCHOOL OFFICIALS:

1.Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis for a determination of residency of the minor, without the requirement of a guardianship or other custody order, unless the school district determines from actual facts that the minor is not living with the caregiver.

2.The school district may require additional reasonable evidence that the caregiver lives at the address provided in item 4.

3. A seal or signature of the court is not required. This form is not required to be notarized.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

1.When signed by a relative,

this affidavit shall confer the same rights to authorize medical care and dental care for the minor that are given to guardians under Section 2353 of the Probate Code. The medical care authorized by a relative caregiver may include mental health treatment subject to the limitations of Section 2356 of the Probate Code.2.A health care service provider who acts in good faith reliance upon a caregiver’s authorization affidavit to provide medical or dental care, without actual knowledge of facts contrary to those stated on the affidavit, is not subject to criminal liability or to civil liability to any person, and is not subject to professional disciplinary action, for that reliance if the applicable portions of the form are completed. A seal or signature of the court is not required. This form is not required to be notarized.

3.This affidavit does not confer dependency for health care coverage

purposes.