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    ConsentChildNonParent

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    kumar2bw
    Consent for Child NonParent

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    ConsentChildNonParent

    Uploaded by

    kumar2bw
    4 views3 pages
    Consent for Child NonParent

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Consent for Child NonParent

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    4 views3 pages

    ConsentChildNonParent

    Uploaded by

    kumar2bw
    Consent for Child NonParent

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 3

    CONSENT FOR MINOR CHILD TO LIVE WITH NON-PARENT

    We are the parents of these minor children (name all the children covered by this form):
    ______________________________________________________________________________
    _____________________________________________________________________________.

    We give permission for our minor children named above to live with (name each):
    _____________________________________ and ____________________________________
    (the Caregiver(s)), effective ______________________ (date this consent starts), until
    ______________________ (date this consent ends), or until we the parents decide it is no
    longer in our children’s best interest.

    We give the Caregiver(s) our permission to do the following for or with the children on our
    behalf [Check all the boxes that apply, and CROSS OUT anything that does not apply, with your
    initials by the crossed-out text]:

    <INPUT TYPE=\ Consent to all medical, vision, and dental care, whether emergency or routine,
    and to obtain Medi-Cal or other health insurance coverage for the children.

    <INPUT TYPE=\ Enroll the children in school and make all school-related decisions for them,
    including, but not limited to: Choosing curriculum, attending parent-teacher conferences,
    participating in IEP or Student Success Team meetings, signing permission slips, and
    enrolling in sports or other extracurricular activities.

    <INPUT TYPE=\ Sign consent forms needed to obtain a California Learner’s Permit and/or
    Driver’s License as each child becomes old enough.

    <INPUT TYPE=\ Travel outside the State of California with the children.

    <INPUT TYPE=\ Obtain a passport for each child and travel outside the United States of America
    with the children. (Both parents must initial): (_____) Parent 1 (_____) Parent 2

    <INPUT TYPE=\ Consent to ear piercing.

    <INPUT TYPE=\ Receive Social Security and other benefits and use them on behalf of the
    children.

    <INPUT TYPE=\ Do anything else for or with the children that we, as their parents, would have
    the legal right to do.

    1
    [Parent or parents signature(s) must be notarized]

    Date:

    _________________________________ _________________________________________
    Print Parent 1 Name Signature Parent 1

    Parent 1 Mailing address: Phone number: _______________________

    ________________________________________ Email: ______________________________

    ________________________________________

    Date:

    __________________________________ _______________________________________
    Print Parent 2 Name Signature Parent 2

    Parent 2 Mailing address: Phone number: _______________________

    ________________________________________ Email: ______________________________

    ________________________________________

    I am/We are the Caregivers authorized by the parents above, and I/we consent to act as
    authorized by the parents. [Caregiver(s) signatures do NOT need to be notarized]
    Date:

    ____________________________________ ____________________________________
    Print Caregiver 1 Name Signature Caregiver 1

    Caregiver 1 Mailing address: Phone number: _______________________

    ________________________________________ Email: ______________________________

    ________________________________________

    2
    ____________________________________ ___________________________________
    Print Caregiver 2 Name Signature Caregiver 2

    Caregiver 2 Mailing address: Phone number: _______________________

    ________________________________________ Email: ______________________________

    ______________________________________

    Instructions:
    <INPUT TYPE=\Notarize parent(s) signatures.
    <INPUT TYPE=\Make sure you check all the boxes that apply to your case.
    <INPUT TYPE=\Initial where needed.
    <INPUT TYPE=\Attach a copy of each child’s birth certificate.
    <INPUT TYPE=\Give a copy of this document to your children’s emergency caregiver(s).

    ACKNOWLEDGMENT / NOTARIZATON

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