Introduction

I, [Your Name], residing at [Your Address], hereby affirm the following facts and statements in support of the authorization granted to [Non-Parental Caregiver's Name], residing at [Caregiver's Address], as the designated caregiver for my child, [Child's Name], born on [Child's Date of Birth].

Statement of Facts

1. I, [Your Name], am the legal parent/guardian of [Child's Name]. The designated caregiver, [Non-Parental Caregiver's Name], is a trusted individual known to me and resides at [Caregiver's Address].

2. Due to unforeseen circumstances [Explain briefly the reason why the parent(s) cannot provide care], I am unable to fulfill my parental duties and responsibilities for [Child's Name].

3. This authorization shall be effective from [Start Date] to [End Date], unless otherwise revoked in writing by me.

4. I hereby grant [Non-Parental Caregiver's Name] the authority to make decisions regarding the health, education, and general welfare of [Child's Name], including but not limited to medical treatment, educational enrollment, and participation in extracurricular activities.

5. I affirm that this authorization is voluntary and granted with full knowledge and consent. I understand that [Non-Parental Caregiver's Name] will act in the best interests of [Child's Name] while under their care.

6. I hereby acknowledge that my signature below is made under oath and that this affidavit is executed with the full understanding of its contents.

Sworn Oath

I, [Your Name], do hereby solemnly affirm under oath that the foregoing statements are true and correct to the best of my knowledge, belief, and understanding.

Signature

[Your Name]
Parent/Legal Guardian

[Date]

[Notary Public's Name]

Notary Public

[Date]

[Caregiver's Name]
Caregiver

[Date]

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