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 (street, apartment number, city, state, zip code):
______________________________________________
______________________________________________
______________________________________________
5. F I am a grandparent, aunt, uncle, or other qualified relative of the minor
(see page 2 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):
F 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.
F 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's 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: ________________________
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JUDICIAL SUBPOENA
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Courtat thethe Honorable
located at
County of
o'clock in theday of noon, and at any recessedin room , on the , 20 , at
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
I
Calendar No.
THE PEOPLE OF THE STATE OF NEW YORK
TO
Index No.
,
American LegalNet, Inc.
www.USCourtForms.com
Court in
Witness, Honorable , one of the Justices of the
day of , 20County,
COURT
COUNTY OF
Plaintiff(s)
-against-
Defendant(s)
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