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LEGALDOCS - Child Care Authorization Questionnaire

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This form allows you to authorize another person to make certain decisions or provisions for your minor child or children. It is similar to a permission slip used in elementary schools. It is important for every person who cares for your child to have the power to authorize emergency medical care. Furthermore, many schools, day care centers, etc. will not allow any person who is not the parent to pick up such a child from the school or center.

This program allows you to grant authorization for up to four children. If you have more than four children, make a second Child Care Authorization to cover the additional children, or make a separate authorization for each child.

To create a Child Care Authorization, complete this Form.


It is only necessary for one parent or guardian to sign this authorization. However, some schools consider it appropriate for both parents to sign, and this Form allows for two signatures.

    The parent or guardian who is granting this child care authorization is:

    Parent/Guardian 1:
    Parent/Guardian 2:

    The full name of the caregiver to whom temporary power is being granted is


    The caregiver is being granted temporary power over the following children:

    Child 1:
    Child 2:
    Child 3:
    Child 4:


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.

Enter the powers that the caregiver may have with regards to

your children in the box below. Begin the sentence with the word "To".

Effective Date: Enter the date on which this authorization will become effective:


Duration: How long will this authorization remain in effect?

Until terminated by the undersigned parents or guardians.

This authorization will terminate on the following date:


Place of Signing: Enter the county and state where this document will be signed:


This completes the information input for your Child Care Authorization. When you Send this Form, this program will prepare a Summary of the Child Care Authorization for your review. Make sure that all facts stated in the Summary are correct in all respects.


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