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Free Massachusetts Caregiver Authorization Affidavit Form - PDF Form Download

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Use this template/form as a Caregiver Authorization Affidavit Form in the State of Massachusetts

massachusetts-caregiver-authorization-affidavit-form


Text version of this Form

———————– Page 1———————–

CAREGIVER AUTHORIZATION AFFIDAVIT
Massachusetts General Laws Chapter 201F

1. AUTHORIZING PARTY (Parent/Guardian)

I, ____________________________, residing at __________________________________

am: (circle one) the parent legal guardian legal custodian of the minor child(ren) listed

below.

I do hereby authorize ____________________________________________, residing at

______________________________________________ to exercise concurrently the rights

and responsibilities, except those prohibited below, that I possess relative to the education and

health care of the minor children whose names and dates of birth are:

______________________________ ___________________________________
name date of birth name date of birth

______________________________ ___________________________________
name date of birth name date of birth

The caregiver may NOT do the following: (If there are any specific acts you do not want the
caregiver to perform, please state those acts here.)
____________________________________________________________________________
____________________________________________________________________________

The following statements are true: (Please read)

• There are no court orders in effect that would prohibit me from exercising or conferring
the rights and responsibilities that I wish to confer upon the caregiver. (If you are the
legal guardian or custodian, attach the court order appointing you.)

• I am not using this affidavit to circumvent any state or federal law, for the purposes of
attendance at a particular school, or to re-confer rights to a caregiver from whom those
rights have been removed by a court of law.

• I confer these rights and responsibilities freely and knowingly in order to provide for the
child(ren) and not as a result of pressure, threats or payments by any person or agency.

• I understand that, if the affidavit is amended or revoked, I must provide the amended
affidavit or revocation to all parties to whom I have provided this affidavit.

This document shall remain in effect until ____________ (not more than two years from today)

or until I notify the caregiver in writing that I have amended or revoked it.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Signature: _________________________________
Printed name: _________________________________
Telephone number: _________________________________

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2. W ITNESSES TO AUTHORIZING PARTY SIGNATURE
(To be signed by persons over the age of 18 who are not the designated caregiver.)

_______________________________ _______________________________
Witness #1 Signature Witness #2 Signature
_______________________________ _______________________________
Printed Name, Address and Telephone Printed Name, Address and Telephone
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________

3. NOTARIZATION OF AUTHORIZING PARTY’S SIGNATURE

Commonwealth of Massachusetts

______________, ss

On this date, _______________, before me, the undersigned notary public, personally appeared
_________________________________________, proved to me through satisfactory evidence of
identification, which was _________________________________, to be the person whose name is signed
on the preceding document, and swore under the pains and penalties of perjury that the foregoing
statements are true.

Signature and seal of notary: _____________________________
Printed name of notary: _____________________________
My commission expires: _____________________________

4. CAREGIVER ACKNOWLEDGMENT

I, ______________________________________, am at least 18 years of age and the above

child(ren) currently reside with me at _____________________________________________.

I am the children’s (state your relationship to the child) _______________________________.

I understand that I may, without obtaining further consent from a parent, legal custodian
or legal guardian of the child(ren), exercise concurrent rights and responsibilities relative
to the education and health care of the child(ren), except those rights and responsibilities
prohibited above. However, I may not knowingly make a decision that conflicts with the
decision of the child(ren)’s parent, legal guardian or legal custodian.

I understand that, if the affidavit is amended or revoked, I must provide the amended
affidavit or revocation to all parties to whom I have provided this affidavit prior to further
exercising any rights or responsibilities under the affidavit.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Signature of caregiver: _____________________________
Printed name: _____________________________
Telephone Number: _____________________________
Date: _____________________________

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