Instructions for the Massachusetts Caregiver Authorization Affidavit

Find answers to common questions about caregiver permissions and learn how to fill out the Caregiver Authorization Affidavit form.

Who can use the Caregiver Authorization Affidavit form?

If a child is living with you, a parent may give you permission to make medical and educational decisions for the child. If the child is living with you and you are not a parent, you are called a “caregiver.”

Do I need to file anything in court if we use this form?

No. This Caregiver Authorization Affidavit form gives the caregiver the right to make decisions without a court order.

What does the caregiver do with this form?

You will need to give a copy of this form to the child’s school, doctor and dentist. You should keep a list of everyone to whom you gave the form, in case you have to let them know about changes. You should make copies for yourself and keep the original in a safe place.

Does this form give custody to the caregiver?

No, this form only gives the caregiver the right to make medical and educational decisions for the child.

If a parent signs this form, can the parent still make these decisions?

Yes, a parent keeps the right to make these decisions as well.

What happens if the caregiver and the parent disagree?

If there is a disagreement, the parent makes the final decision.

How long does this permission last?

It is good for up to 2 years. You will need a new one every 2 years.

Can a parent change his or her mind?

Yes. He or she needs to write a letter to the caregiver, saying that the caregiver no longer has permission to make these decisions. Please be sure to sign the letter and include the date. The parent and the caregiver each gives a copy of this letter to the child’s school, doctor and dentist.

How to fill out the Caregiver Authorization Affidavit form

Parent

• The parent fills out the front page under the heading “Authorizing Party.”
• The parent must sign this form in front of two witnesses (who are not the caregiver) and a notary public. The witnesses and the notary sign on the back page.
• Notaries are often available at banks and courts. You can also find a notary in the yellow pages. Please note that you will need to show a picture I.D. to the notary. There may be a charge to have the form notarized.

2 years  Caregiver permission is good for up to 2 years

Caregiver

The caregiver fills out the last paragraph on the back page called “Caregiver Acknowledgment.”

Both the parent and the caregiver should carefully read the form before signing, since you are swearing that the information in it is true.