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Child Care Authorization Parent(s)/guardian(s) granting this child care authorization 1. 2. Full name of the caregiver to whom temporary power is being granted Name: The caregiver is being granted temporary power over the following children: Child 1 Child 2 Child 3 Child 4 Child 5 Child 6 Duration Until terminated by the undersigned parents or guardians This authorization will terminate on the following date: Effective Date Caregiver Powers The caregiver shall have the following powers with regard to the above-named children (check all that apply): To seek medical care for the children, including, but not limited to, visits to the doctor and/or hospital. To authorize medical treatment or medical procedures in the event of an emergency situation. To provide food and shelter for the children, and to make decisions regarding their day-to-day activities. To transport the children in the caregiver's car, including authorization to pick the children up from school or daycare. Other: Signature Date Signature Date