What is a Caregiver’s Affidavit?
A Caregiver’s Affidavit is a written form for caregivers of minors under the age of 18 who are not a biological parent. A Caregiver’s Affidavit can help prevent delays in meeting a child’s medical and/or educational needs. However, it does not grant the caregiver the right to obtain medical records, nor does it serve as authorization for the disclosure of the minor's protected health information.
For purposes of this affidavit, a qualified relative may include a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, godparent, member of the minor's tribe or clan, an adult with whom the minor has a significant bond, or certain relatives with the prefix “grand” or “great.”
The affidavit is authorized by the Kinship Guardianship Act and is signed by the caregiver as a sworn statement. By signing the form, the caregiver confirms that the minor lives in their home, that they are at least 18 years old, and that the information provided is true and correct.
When completing a Caregiver’s Affidavit, what should you keep in mind?
• Items 1–4 are used to authorize enrollment of a minor in school and school-related medical care.
• Items 5–8 are additionally required if the caregiver needs to authorize other medical care.
• The caregiver must provide information about the minor, their relationship to the minor, their own date of birth, and identification information.
• The caregiver may need to confirm whether the parent or legal guardian has been notified or whether they were unable to be contacted.
• The form must be signed and notarized.
• The affidavit is not valid for more than one year from the date it is signed.
• The caregiver should not sign the form if any of the statements are incorrect.
Why might a caregiver need this affidavit?
A caregiver may need this affidavit when they are caring for a minor in their home but are not the biological parent or legal guardian. Without written documentation, schools or healthcare providers may not know whether the caregiver has authority to act on behalf of the minor. Depending on which sections are completed, the affidavit may allow the caregiver to:
• Authorize school enrollment
• Authorize school-related medical care and other medical care
• Assist with dental or mental health care
• Provide documentation that the minor is living with and being cared for by the caregiver
Caregiver’s Affidavit PDF