Caregiver Authorization Letter - Template, Sample Form

CAREGIVER AUTHORIZATION AND CONSENT

________ (the “Parent/Legal Guardian”)
________
Telephone: ________
Email: ________

Date: ________

________
________

Re: Caregiver Authorization and Delegation of Parental Powers

To Whom It May Concern:

§ 1. Purpose and Parties. The purpose of this letter (this “Authorization”) is to advise you that I, ________, residing at ________, in my capacity as the ________ and parent or legal guardian of the minor child identified below, have granted the authority described herein to ________, residing at ________, telephone ________ (the “Caregiver”), while the Caregiver is caring for the following minor child (the “Child”):

Name of Child: ________
Date of Birth: ________

§ 2. Term. This grant of temporary authority shall commence on ________ and shall remain in full force and effect until ________, unless earlier revoked in writing by the undersigned Parent/Legal Guardian.

§ 3. Scope of Authority. During the term set forth above, the Caregiver is hereby authorized and empowered to act on my behalf with respect to the Child, including, without limitation, the authority to do the following:

(a) Pick up and transport the Child to and from school and afterschool activities;

(b) Seek and obtain appropriate medical, dental, surgical, and emergency care, treatment, or attention on behalf of the Child as the circumstances may require, including, but not limited to, visits to a physician, dentist, urgent care facility, and/or hospital;

(c) Consent to and authorize medical, surgical, dental, or hospital treatments, examinations, diagnoses, anesthesia, and procedures in an emergency situation where I cannot be reached, in accordance with applicable state law;

(d) Communicate with health care providers and access the Child's medical and health information to the extent permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164;

(e) Communicate with school officials, access the Child's educational records to the extent permitted under the Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g, and explain the Child's absences from school;

(f) Sign release, consent, and permission forms for the Child's participation in sports and athletic activities;

(g) Sign release, consent, and permission forms for the Child's participation in field trips and school-sponsored events; and

(h) Take such other reasonable actions as are necessary for the day-to-day care, safety, and welfare of the Child during the term hereof.

§ 4. Medical Insurance. The Child is covered under the following health insurance: Carrier ________; Policy/Member No. ________. The Child has the following known allergies, medical conditions, or medications: ________.

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit voluptate velit esse cillum dolore eu fugiat nulla pariatur lorem ipsum dolor sit amet consectetur adipiscing elit sed.

§ 6. Revocation. I reserve the right to revoke this Authorization at any time by delivering written notice of revocation to the Caregiver and to the addressee of this letter. Absent such revocation, this Authorization shall expire automatically on the termination date set forth in § 2.

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit voluptate velit esse cillum dolore eu fugiat nulla pariatur lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut.

§ 8. Governing Law. This Authorization shall be governed by and construed in accordance with the laws of the State of ________, without regard to its conflict-of-laws principles.

If you need any additional information from me, please contact me at the above address or here:

________

Thank you for your cooperation and assistance in this matter. I appreciate your attention to the authority granted herein and your willingness to honor it during the period specified above.

Sincerely,

_______________________________
________
Parent/Legal Guardian

ACKNOWLEDGMENT (NOTARIZATION)

State of ________
County of ________

On this ________, before me, the undersigned notary public, personally appeared ________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the foregoing instrument, who acknowledged that he or she executed the same voluntarily for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

_______________________________
Notary Public Signature

Printed Name: ________
My Commission Expires: ________