Child Care Authorization Form

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Child Care Authorization
Parent(s)/guardian(s) granting this child care authorization
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