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FAMILY CODE SECTION 6550-6552

6550. (a) A caregiver’s authorization affidavit that meets the
requirements of this part authorizes a caregiver 18 years of age or
older who completes items 1 to 4, inclusive, of the affidavit
provided in Section 6552 and signs the affidavit to enroll a minor in
school and consent to school-related medical care on behalf of the
minor. A caregiver who is a relative and who completes items 1 to 8,
inclusive, of the affidavit provided in Section 6552 and signs the
affidavit shall have 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 this
caregiver who is a relative may include mental health treatment
subject to the limitations of Section 2356 of the Probate Code.
(b) The decision of a caregiver to consent to or to refuse medical
or dental care for a minor shall be superseded by any contravening
decision of the parent or other person having legal custody of the
minor, provided the decision of the parent or other person having
legal custody of the minor does not jeopardize the life, health, or
safety of the minor.
(c) A person who acts in good faith reliance on 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 affidavit are
completed. This subdivision applies even if medical or dental care is
provided to a minor in contravention of the wishes of the parent or
other person having legal custody of the minor as long as the person
providing the medical or dental care has no actual knowledge of the
wishes of the parent or other person having legal custody of the
minor.
(d) A person who relies on the affidavit has no obligation to make
any further inquiry or investigation.
(e) Nothing in this section relieves any individual from liability
for violations of other provisions of law.
(f) If the minor stops living with the caregiver, the caregiver
shall notify any school, health care provider, or health care service
plan that has been given the affidavit. The affidavit is invalid
after the school, health care provider, or health care service plan
receives notice that the minor is no longer living with the
caregiver.
(g) A caregiver’s authorization affidavit shall be invalid, unless
it substantially contains, in not less than 10-point boldface type
or a reasonable equivalent thereof, the warning statement beginning
with the word “warning” specified in Section 6552. The warning
statement shall be enclosed in a box with 3-point rule lines.
(h) For purposes of this part, the following terms have the
following meanings:
(1) “Person” includes an individual, corporation, partnership,
association, the state, or any city, county, city and county, or
other public entity or governmental subdivision or agency, or any
other legal entity.
(2) “Relative” means a spouse, parent, stepparent, brother,
sister, stepbrother, stepsister, half brother, half sister, uncle,
aunt, niece, nephew, first cousin, or any person denoted by the
prefix “grand” or “great,” or the spouse of any of the persons
specified in this definition, even after the marriage has been
terminated by death or dissolution.
(3) “School-related medical care” means medical care that is
required by state or local governmental authority as a condition for
school enrollment, including immunizations, physical examinations,
and medical examinations conducted in schools for pupils.

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:

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. “Qualified relative,” for purposes of item 5, means a spouse,
parent, stepparent, brother, sister, stepbrother, stepsister, half
brother, half sister, uncle, aunt, niece, nephew, first cousin, or
any person denoted by the prefix “grand” or “great,” or the spouse of
any of the persons specified in this definition, even after the
marriage has been terminated by death or dissolution.

2. The law may require you, if you are not a relative or a currently
licensed foster parent, to obtain a foster home license 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, you are required to notify
any school, health care provider, or health care service plan to
which you have given this affidavit. The affidavit is invalid after
the school, health care provider, or health care service plan
receives notice that the minor no longer lives with you.

4. If you do not have the information requested in item 8
(California driver’s license or I.D.), 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.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS:

1. A person 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.

2. This affidavit does not confer dependency for health care
coverage purposes.