• File: JFA-E-3 - CAREGIVER/AFFIDAVIT


    File: JFA-E-3

    CAREGIVER/AFFIDAVIT

    Massachusetts General Laws Chapter 201F

    1.AUTHORIZING PARTY (Parent/Guardian)

    I, , residing at

    am: (circle one) the parentlegal guardianlegal custodianof 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:

    namedate of birthnamedate of birth

    namedate of birthnamedate of birth

    Parent/Guardian, please list the reason(s) why the child(ren) is living in this home:

    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 ant      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:

    2.WITNESSES TO AUTHORIZING PARTY SIGNATURE

    (To be signed by persons over the age of 18 who are not the designated caregiver.)

    Witness #1 SignatureWitness #2 Signature

    Printed Name, Address and TelephonePrinted 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 the Affidavit prior to further exercising any rights or responsibilities under the Affidavit.

    I understand the per pupil cost of student tuition may be charged to the parent/guardian and/or caregiver should it be determined that the child(ren) is not living in Sharon or is living in Sharon for the sole purpose of attending Sharon Public Schools.

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

    Signature of caregiver:

    Printed name:

    Telephone Number:

    Date: