PDF Template

Caregiver Authorization Affidavit

Download a blank template to fill in by hand

This template includes fields for:

  • Your Full Legal Name (Parent / Affiant)
  • Your State ID / Driver's License Number
  • Child's Full Legal Name
  • Child's Date of Birth
  • Caregiver's Full Legal Name
  • Caregiver's Residential Address
  • Authorization Start Date
  • Authorization End Date
  • Scope of Authorization
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How to Use This Template

  1. 1
    Download and print

    Download the PDF template and print it out on A4 paper.

  2. 2
    Fill in your details

    Complete all the fields with a blue or black pen. Write clearly and legibly.

  3. 3
    Get notarized by a Notary Public

    Take the completed form to any Notary Public. The Notary Public will verify your identity and witness your signature.

  4. 4
    Bring your ID

    Remember to bring your government-issued ID or passport when going to get your affidavit notarized.