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CONTENTS

Who Should Read this Pamphlet? ............................................................... 3 Guardianship ................................................................................................. 3 Guardianship Clinic ...................................................................................... 5 Terminology .................................................................................................. 8 Guardianship Law ........................................................................................ 11 Rights and Responsibilities of a Guardian ................................................ 18 Financial Support of the Minor .................................................................. 20 Standards for Appointment of Guardian ................................................... 22 Termination of Guardianship and Contested Guardianship .................... 23 Helpful Phone Numbers ............................................................................. 24 Public Counsel Income Guidelines (Appendix A) ..................................... 25 Caregiver’s Affidavit (Appendix B) ............................................................ 27 Child Care Authorization (Appendix C) .................................................... 30

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WHO SHOULD READ

THIS PAMPHLET?

Are you..

1. A non-parent caring for a child and you need help getting legal

guardianship (custody) of him/her through Probate Court?

2. Already a legal guardian of a child through Probate Court, and you

want to end the guardianship and return the child to a parent or to

another caregiver?

3. A parent whose child is in a legal guardianship and you want to end

the guardianship and get your child back?

4. A parent who got a notice saying someone wants to become your

child’s guardian, and you want to object and get your child back?

5. A parent, relative or family friend who wants visitation with a child in

guardianship?

What is legal guardianship?

Legal guardianship of the person of a minor suspends the parents’ right

to the custody of their child and places custody with the legal guardian. It

does not permanently terminate parental rights. This means the parent

can petition to terminate the guardianship, and get custody back. The

parent also remains financially responsible for the child. To establish

legal guardianship, you must go to court and obtain a court order. At the

guardianship hearing the clerk will stamp the judge’s signature on the

Order Appointing Guardian of Minor. This document, along with the Let-

ters of Guardianship is your proof of legal guardianship. After a guardi-

anship has been granted, the minor is called a "ward."

GUARDIANSHIP

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Where do I go for help?

The Guardianship Clinic is located at the Superior Court in down-

town Los Angeles. Assistance is available in English and Spanish.

Pro Per Guardianship Clinic

Los Angeles Superior Court

Stanley Mosk Courthouse

111 N. Hill Street, Room 230

Los Angeles, CA 90012

Monday through Wednesday

9:30 a.m. - 3:30 p.m.

Please arrive in person by 9:00 a.m. to sign-in.

Clinic staff: Supervising Attorney Ylianna Perez-Guerrero, Staff

Attorney Kristie Lutz and Senior Social Worker Beth Tsoulos, assist

people at the Guardianship Clinic.

Pro Per means you don't have an attorney and are acting as your

own attorney in court.

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GUARDIANSHIP CLINIC Are there any requirements to get

help at the clinic?

You must:

1. Meet the low-income guidelines of Public Counsel. See Appendix A

for our income guidelines.

2. If you want to become a child’s guardian, the child must be living

with you.

3. The minor must currently live in Los Angeles County.

What happens at the clinic?

We help people on a first come-first served basis according to our

sign-in sheet. We do not take appointments.

Please arrive at the clinic as early in the day as possible. We help you fill out all the paperwork required to file for guardian-

ship, tell you where to go file your paperwork and explain the court

process.

Do I have to pay anything?

If you qualify for our services there is no fee. The court fees are

$1,465.00. There is an additional $60.00 fee if you also file a petition for

temporary guardianship. However, you may qualify for a fee waiver if

you are low-income.

Please arrive early. There is no guarantee that we will be able

to help you on the day you come in.

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If you receive any of these benefits

you do not have to pay the court

fees:

CalWORKS

CalFresh (Food Stamps)

Medi-Cal

SSI (Supplemental Security Income)

General Relief (GR) or General Assistance (GA)

IHSS (In-Home Support Services)

CAPI (Cash Assistance Program for Aged, Blind, Disabled)

What do I need to bring?

Information about your income and expenses to apply for a fee waiv-

er, such as:

An employment pay stub

Your EBT card

Bank statement

Copies of bills

2. Information to fill out the Guardianship Clinic intake form. (See Ap-

pendix B).

3. Children should stay home or go to school if possible. However, if

you do not have any child care options, there is a supervised child

waiting room on the second floor.

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What doesn’t the clinic help with?

If you want to become the legal guardian of a child who has an “estate” (money or property), the clinic does not handle this process, and you need an attorney. The Los Angeles County Bar Association has a list of attorneys with experience in probate and guardianship cases. They can be reached at 213-243-1525 or at their website at www.lacba.org We do not represent you in court. There is no attorney client relation-ship between you and the attorneys at the clinic, and your conversations with us are not confidential.

What if the child has other needs?

At the Guardianship Clinic you can fill out a screening form if the child

you are caring for has unmet health, education, benefits or other needs,

and we will provide referrals or other assistance.

Help is available in Spanish but if you are able to bring an interpret-er, it is helpful. Hay ayuda en español, pero si usted puede traer un intérprete, es útil.

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TERMINOLOGY

Definition of words used in

this pamphlet:

Consent and Waiver of Notice: The document that a child, parent, grandparent or sibling can sign if they agree to the guardianship. Department of Children and Family Services (“DCFS”) Social Worker: The agency which conducts the home visit and investigation for the court if you are unrelated to the minor. Guardianship: The term used when someone who is not the child’s parent has custody. Guardianship allows you to make decisions about the care, custody, and education of a minor. A Guardianship is valid un-til the child is eighteen or until ended by the court order. Guardian/Proposed Guardian: The non-parent caregiver who has legal guardianship (custody) of the minor or who is asking the court for legal guardianship of the minor. Hearing (Temporary and General): The court date when a judge will consider your case. He or she will decide if the guardianship is neces-sary to serve the best interests of the minor. Letters of Guardianship: The document issued by the court and filed after you obtain the Order Appointing Guardian of Minor and which makes the Order valid.

Minor: Someone under the age of 18, a child.

After the guardianship hearing (temporary or permanent)

you must file the Order Appointing Guardian and Letters of

Guardianship.

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Notice of Hearing: The document you use, along with a copy of the

petition, to inform relatives and two state agencies of the date, time and

place of the guardianship hearing, including:

Parents of the minor(s)

Grandparents on both sides (maternal and paternal)

Siblings 12 years of age or older

Person having the care of the minor (usually the proposed guardian)

The minor if 12 years of age or older

Department of Children and Family Services (DCFS)

Department of Public Social Services (DPSS) (unrelated guardians

only)

Probate Court Investigator: A court employee who does an investiga-tion for the court if you are related to the minor. The investigation report helps the judge determine what is in the best interest of the minor and whether to grant the guardianship. Proof of Service: The document you must file with the court that shows all parties were given notice of the hearing and a copy of the peti-tion. The process of notifying all parties is called “serving” them.

If a parent or other relative has signed the Consent and Waiver of

Notice form, you do not need to notify them, but you must always

notify DCFS.

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Temporary Guardianship: In cases where there is a risk of immedi-ate harm to the child, the court may grant you a court hearing within 5-7 days so you can ask for temporary guardianship. There must be an urgent need – for example, the child needs someone to consent for surgery. A petition for temporary guardianship cannot be filed on its own, but only along with a petition for general guardianship. Temporary guardianship gives you custody of the child only until the date of the per-manent guardianship hearing. Order Appointing Guardian of Minor: The document signed by the judge and filed with the court that gives you guardianship of the minor. Petition: The document in which you ask the court to appoint you as guardian, and explain why the guardianship is necessary to serve the best interests of the minor.

How do I get a guardianship? You must file a petition and related documents with the Probate Court.

What if the child already has a case in juvenile court? If the child was removed from the parents due to abuse or neglect and has an open case in juvenile court, you cannot ask the probate court for guardianship. Instead, you must contact the child's DCFS social worker, or the child's probation officer, if you want to become the child's guardi-an.

GUARDIANSHIP LAW

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Do I have to go to court?

Yes. A judge will decide at a hearing if the guardianship should be

granted. If you ask for temporary guardianship, then there will be two

hearings - one in 5-10 days from the day you file your paperwork and the

general guardianship hearing about 6-8 weeks later.

Does an investigator or social

worker come to my home?

Maybe. If you are not related to the child, before the hearing a

social worker from DCFS will call you and set up a time to visit your

home and interview you and the child. Everyone who lives in the home

must be present for the interview.

Sometimes when DCFS investigates a report of child abuse or ne-glect, and a child is living with a relative or family friend, DCFS will tell the caregiver to get a guardianship in Probate Court, so they can close the case once a guardianship is in place. If you are in this situation, the Guardianship Clinic can give you infor-mation to help you decide if a probate guardianship is the best option for you and the child. If you have questions, ask us. The Pro Per Guardianship Clinic only assists with guardianships in Probate Court.

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If you are related to the child, you will receive a notice by mail of a "Case

Review Conference." During this appointment, the court investigator will

interview you and the child in Room 233 of the court (at 111 N. Hill St) or

at the Lancaster court if you live in the Antelope Valley. You will be

asked to complete a form prior to the appointment and to bring copies of

the child's medical and educational records.

The investigator or social worker will also complete background checks

on all adults living in your household to make sure no one has a serious

criminal record or a history of child abuse or neglect. They will then

write a report which will be considered by the judge in deciding whether

to grant the guardianship. The report by the investigator or social worker

is not part of the public court file. However, the proposed guardian or

the parent can ask for a copy of the report directly from the social worker,

from the investigator's office in Room 208, or on the day of the court

hearing from the court clerk.

Do I have to let the parents

know about my petition for

guardianship?

General Guardianship: Yes. Both the mother and father of the minor

must receive a copy of the guardianship petition and Notice of Hearing

documents. This is called “serving” them. Someone who is 18 years of

age or older and who is not a party to the case - not you! - must serve the

minor’s parent(s) in person. Since the petition has your address and

phone number on it, please let the clinic know if telling either parent this

information would put you or the child at risk.

It is important for you and the child to be honest and coopera-

tive with the investigator or social worker. The judge will read

and rely on their report when deciding whether to grant the

guardianship.

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Please come back to the Pro Per Guardianship Clinic after your

temporary hearing or at least 20 days before your hearing on

general guardianship for help with notifying parents and rela-

tives. The judge will deny your guardianship petition if you

cannot prove that you served parents and relatives correctly!

Temporary Guardianship: Yes. You need to notify the parents of the

date, time and place of the hearing at least 5 days in advance. You must

make your best efforts to notify them in person, but if you are unable to

do so, you must at least attempt to notify them by phone.

Is a notarized letter a valid

guardianship?

No. You cannot obtain legal guardianship through a notarized letter, or

through a will. Legal guardianship requires a court order.

Do I need a legal guardianship to

enroll a child in school and get

health care for the child?

No. If all you need to do is enroll a minor in school, you can use a

Caregiver’s Affidavit (See Appendix B). California law allows a relative or

family friend who is caring for a child to use this form to prove that the

minor lives in the caregiver’s home in order to enroll the minor in school

in the caregiver’s district and authorize school-related health care (such

as immunizations).

If the caregiver is a relative, the Caregiver's Affidavit can also be used to

make general health care decisions for the child.

Grandparents and siblings 12 years of age or older also must be

given notice of the hearing and a copy of the petition.

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Do I need legal guardianship to

obtain financial assistance and

Medi-Cal?

Maybe. You do not need a legal guardianship to obtain benefits if you

are related to the child. You must provide proof of relationship, for ex-

ample, have the child’s birth certificate and the birth certificate of the

family member that links you to the minor (if you are the minor’s mater-

nal grandmother you would need your daughter’s birth certificate and the

minor’s birth certificate). If you do not have the birth certificates, you

can use other documents, such as baptismal or education records, or if

you don’t have anything else, you may even sign an affidavit.

If you are not related to the child, then you need to obtain legal guardian-

ship to apply for cash aid, but you can obtain Medi-Cal for the child with-

out first obtaining a legal guardianship.

What if I just want a family member or friend to be able to consent to medical treatment for my child, but do not want to give them guardianship? You can give someone authority in writing to consent to medical and

dental care for your child. You should have this document notarized,

though it is not required. See Appendix C for a sample.

Please see the section entitled “Financial Support of the Minor” for

more information.

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What happens in Probate Court?

1. You must arrive on time. Guardianship hearings in the Central dis-

trict court start at 10:30 a.m. You should plan to be there no later

than 10:15 a.m.

2. You must bring the child if he/she is four years of age or older.

3. The court may provide an interpreter if you are not comfortable

speaking or understanding English. If your primary language is

Spanish, you can request an interpreter from the court clerk just

before the hearing. If your primary language is not English or

Spanish, you should bring your own interpreter, as the court will

probably not have one available. The interpreter must be over the

age of 18 and not a party to the case.

4. Please remember to bring all the paperwork that we prepared for you

at the Clinic, including your Order Appointing Guardian of Minor

and Letters of Guardianship, your set of copies and any other

documents you need to file.

5. When you arrive at the courtroom, go in, sit down and wait for

instructions from the court clerk.

6. If the bench officer that day is a Commissioner and not a Judge, the

clerk will ask you to sign a form agreeing to have the Commissioner

hear your case. This form is called a stipulation. If you do not agree

to have the Commissioner hear your case, do not sign the stipulation

and your case will be transferred to a courtroom with a Judge.

The difference between a Commissioner and a Judge is that a

Commissioner is appointed by County officials and a Judge is

elected by voters.

7. If you have any documents to hand in, such as Notice of Hearing or

Consent and Waiver of Notice forms, give them to the clerk before

the hearing. The clerk is in charge of the courtroom until the judge

comes out and takes the bench.

8. When the judge takes the bench you cannot talk. You cannot eat or

drink in the courtroom.

9. Your case will be called by the minor’s last name and a number,

starting by “4001.” For example, “4001” will be called first, “4002”

second, and so forth. The docket sheet posted outside the courtroom

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will list your number . When your case is called, the proposed guardi-

an(s) and the child should walk up to the table facing the judge.

10. Each person will state her name, spell her last name and indicate if

she was sworn. If you were present in court while the bailiff recited

the oath and you raised your right hand and faced the flag, you were

sworn.

Example: “My name is Rosa Mendez, M-E-N-D-E-Z and I have

been sworn.”

11. If you haven’t been sworn in yet, the clerk will swear you in when

your case is called. The judge may ask you or the child a few simple

questions to determine if you are willing and able to care for the child

and if the child is well cared for in your home. The judge will usually

already have the report from the investigator or social worker and

may not need to ask you any questions.

12. The judge will also ask if you have submitted Notice of Hearing or

Consent and Waiver of Notice forms for parents, grandparents, DCFS

(and DPSS if you are an unrelated guardian). You will have to show

proof that you did this.

13. If the judge grants the guardianship, take your seat and wait for the

clerk to call you to have your Order Appointing Guardian signed and

filed.

14. If the judge continues the hearing to a later date, write the date down

and return on that day with any additional documents requested by

the judge. The court will not send you a reminder of the court hear-

ing by mail.

15. If the judge denies your guardianship, you may petition again at a

later time as long as your case was “denied without prejudice.”

What do I do after court?

After the hearing you need to go to room 429 on the fourth floor to have

the Letters of Guardianship issued and certified. To request certified

copies, fill out a white triplicate form. If you have a fee waiver, the certi-

fied copy is free of charge. If you do not have a fee waiver, it will cost you

about $16 to get a certified copy of the court order.

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The Order Appointing Guardian and certified Letters of

Guardianship are your proof of guardianship.

After a hearing on temporary guardianship please return to the Pro Per

Guardianship Clinic for help with serving notice of the hearing on gen-

eral Guardianship, if you have not already done so.

What rights do I have as a guardian?

1. You have the same rights as a parent to consent to health care for the

child, with a few exceptions. See the Public Counsel brochure

“Health Care and Teens” for more information. We can provide you

with a copy at the Pro Per Guardianship Clinic.

2. You can consent to a minor obtaining a driver’s license. By signing

the DMV (Department of Motor Vehicles) application, you agree to

be responsible for any damages caused by the minor’s driving (up to

a limit set by law). You must have auto insurance to cover the minor.

You can withdraw consent at any time by filing a DMV form.

3. You can decide where the child goes to school and request special

education services for the child. No special language is needed on

your Letters of Guardianship for you to be able to do this. If you are

a guardian and are having trouble getting special education services

for your child, contact Public Counsel.

RIGHTS AND RESPONSIBILITIES

OF A GUARDIAN

You must complete this process after your hearing on tempo-

rary guardianship as well.

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What responsibilities do I have as a guardian? 1. You are responsible for the care, custody, control and education of

the minor.

2. You can decide where the child lives within California, but if you

move (or you allow the child to live with someone else) you must

inform the court and the child’s relatives of the child's new address.

Come to the Guardianship Clinic for assistance in filing these forms.

If you decide to allow the child to live with someone else, you are still

responsible for the child as long as you are the legal guardian.

3. You may not move outside of California without court permission.

Come to the clinic for assistance.

4. You may have to pay for any harm or damage caused by the child to

other people or property (such as car accidents, fights, graffiti or van-

dalism) if you did not properly supervise the child and take steps to

control the child's behavior.

What limits are there on my rights as a guardian? The court may include limitations in the Order Appointing Guardian of

Minor. For example, the judge may ask you to follow visitation orders

between the child and parents or siblings.

You cannot place the child in a mental hospital or other facility without

the child's consent, or consent to use of experimental drugs, electroshock

treatment, or sterilization of the child.

What about visitation for parents?

You have the right and responsibility to decide what is best for the child,

concerning visits with parents and relatives, unless there is a court order.

If there is a conflict about visitation, the court may send you and the par-

ents or other relatives to mediation to agree on a visitation schedule.

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Guardianship does not take away the parents’ responsibility to

support the child. Guardians often agree to support the child

themselves, but this is not required by law.

How can I get financial help to care for the child? If you are related to the child, you can receive “CalWORKs” benefits for

the child with or without guardianship. If you are low-income, you can

receive a full CalWORKs grant, which would include you as well as the

child. If you are not low-income, you can receive a "child only" or "non-

needy caretaker relative" CalWORKs grant. If you are a relative and are

told that you do not qualify for CalWORKs because you do not have

guardianship or your income is too high, call Public Counsel for assis-

tance.

If you are not related to the child, you can receive state foster care pay-

ments, regardless of your income. The state foster care payments are

higher than the CalWORKs grant. The amount of the payment will vary

depending on the child's age. You can also receive higher payments if

you are caring for a child with a disability or who has significant emotion-

al or mental health problems.

If you apply for CalWORKs or foster care payments, the County may seek

child support from the child's parents.

FINANCIAL SUPPORT OF THE MINOR

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What is the process for applying for CalWORKs? Go to the Department of Public Social Services (DPSS) office nearest

your home to complete an application. If you have already obtained

guardianship (even temporary) take your Order Appointing Guardian of

Minor and Letters of Guardianship with you. You should expect a long

wait.

What is the process for applying for foster care payments? After obtaining guardianship (even temporary) call the Department of

Children and Family Services at (213) 765-7260 between the hours of

9 a.m. and 5 p.m. Monday-Friday and say: “I am an unrelated legal

guardian through Probate Court and am requesting foster care pay-

ments.” Your home will need to be approved as a suitable placement for

the minor, which involves a home visit and completing an application.

Eligibility for payment will begin on the date you call the hotline, but it

may take 30-45 days to be approved and for payments to begin. The mi-

nor must be a U.S. citizen, permanent resident, or qualified immigrant.

If you have trouble getting CalWORKs or foster care benefits

call Public Counsel or one of the legal services providers listed

in the back of this brochure.

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What if the child was not born

in the United States and is

undocumented?

If the child is undocumented a guardian may not obtain CalWORKs, gen-

eral Medi-Cal or foster care benefits, but the child may be eligible for

other health care benefits such as California Children’s Services, minor

consent Medi-Cal and emergency Medi-Cal. Go to the DPSS office near-

est your home or call 888-747-1222 to have an application mailed to you.

If a minor has been abused, abandoned, or neglected by his or her par-

ents and is not likely to return to the parents' custody, the minor may be

eligible under a federal law to apply for a “green card” from the United

States Citizenship and Immigration Services—USCIS (formerly called the

INS.) Ask at the Guardianship Clinic for information.

How does the court decide whether

to grant the guardianship?

At the hearing, the judge will appoint a guardian if it appears necessary

to serve the best interests of the child, and, if a parent objects, the court

must also find that parental custody is detrimental to the child. The court

will also consider the proposed guardian’s concern for and interest in the

child's welfare, and the child's own wishes.

STANDARDS FOR APPOINTMENT

OF GUARDIAN

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Can a guardianship be ended?

Yes. A guardianship of the person of a minor automatically ends when

the child turns 18, dies, is adopted, or gets married. Also, the child, the

guardian, or a parent can ask the court to end the guardianship and re-

turn the child to the parents' custody, or appoint a new guardian.

The court will end the guardianship if the guardianship is no longer nec-

essary, or in the best interests of the minor. The court can remove the

guardian and appoint a new guardian if the guardian commits a crime or

acts in a way that harms the child.

What if I am a parent and want to

contest the guardianship?

You should come to court for all hearings, and you can also file a written

objection to the guardianship. The Guardianship Clinic can help you pre-

pare and file your objection.

If you want an attorney to represent you, limited assistance may be avail-

able through the Legal Aid Foundation of Los Angeles, Maynard Toll

Center located in the Central District courthouse:

111 N. Hill St., Room 245 or call 1-800-399-4529. For a referral to a pri-

vate attorney contact the Los Angeles County Bar Lawyer Referral at

213/243-1525 or visit their website at www.lacba.org.

If you have questions about guardianship, please contact Public Coun-

sel’s Children’s Rights Project at 213/385-2977 extension 500 or 1-800-

870-8090 extension 500 or come to the Pro Per Guardianship Clinic in

the Central district courthouse.

TERMINATION OF GUARDIANSHIP

AND CONTESTED GUARDIANSHIPS

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Probate Office ............................................................................213-974-5471 Probate Investigator’s Office, Room 208................................ 213-974-5859 DCFS Guardianship Investigations Clerk .............................. 323-526-6892 Department 5, 9, 11, or 29.........................................................213-974-5471

Support Services 211 LA County (formerly Info Line) ........................... 800-339-6993 or 211 Kinship Resource Center .................................................... 888-MYGRAND Grandparents As Parents ........................................................818-264-0880 Kinship in Action (South LA) ................................................. 323-750-9087 Child Abuse Hotline ............................................................... 800-540-4000

Legal Services Public Counsel Children’s Rights Project ................... 213-385-2977 x.500 Alliance for Children’s Rights ................................................. 213-368-6010 Bet Tzedek ............................................................................... 323-939-0506 Legal Aid Foundation of Los Angeles .................................... 800-399-4529

HELPFUL PHONE NUMBERS

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PUBLIC COUNSEL INCOME

GUIDELINES

Appendix A

Your income must fall within these guidelines in order to qualify for our

free legal services.

Household of: Annual Income: Monthly Income:

1 $ 36,487.50 $ 3,040.63

2 $ 41,700.00 $ 3,475.00

3 $ 46,912.50 $ 3,909.38

4 $ 52,087.50 $ 4,340.63

5 $ 56,287.50 $ 4,690.63

6 $ 60,450.00 $ 5,037.50

7 $ 64,612.50 $ 5,384.38

8 $ 68,775.00 $ 5,731.25

For each additional

household member

add:

$ 4,167.00 $ 347.25

25

Appendix B Use of this affidavit is authorized by Part 1.5 (commencing with Section

6550) of Division 11 of the California Family Code.

Instructions: Completion of items 1-4 and the signing of the affidavit is

sufficient to authorize enrollment of a minor in school and authorize

school-related medical care. Completion of items 5-8 is additionally re-

quired to authorize any other medical care. Print clearly.

The minor named below lives in my home and I am 18 years old or older.

1. Name of minor: ____________________________________

2. Minor’s birth date: __________________________________

3. My name (adult giving authorization): _____________________

4. My home address: __________________________________

Number Street Apt. # __________________________________ City State Zip 5. I am a grandparent, aunt, uncle, or other qualified relative of the

minor (see next page for a definition of “qualified relative”).

6. Check one or both (for example, if one parent was advised and the

other cannot be located):

I have advised the parent/s or other person/s having legal custody of

the minor of my intent to authorize medical care, and have received

no objection.

I am unable to contact the parent/s or other person/s having legal

custody of the minor at this time, to notify them of my intended

authorization.

7. My date of birth: ___________________________________

8. My California drivers license or identification card number:

___________________________

I declare under penalty of perjury under the laws of the State of

California that the foregoing is true and correct.

Signed: ___________________________ Dated: ___________

CAREGIVER’S AFFIDAVIT

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Notices:

1. This declaration does not affect the rights of the minor’s parents or le-

gal guardian regarding the care, custody, and control of the minor, and

does not mean that the caregiver has legal custody of the minor.

2. A person who relies on this affidavit has no obligation to make any fur-

ther inquiry or investigation.

3. This affidavit is not valid for more than one year after the date on

which it is executed.

TO CAREGIVERS:

1. “Qualified relative,” for purposes of item 5, means a spouse, parent,

stepparent, brother, sister, stepbrother, stepsister, half-brother, half-

sister, uncle, aunt, niece, nephew, first cousin, or any person denoted by

the prefix “grand” or “great,” or the spouse of any of the persons specified

in this definition, even after the marriage has been terminated by death

or dissolution.

2. The law may require you, if you are not a relative or a currently li-

censed foster parent, to obtain a foster home license in order to care for a

minor. If you have any questions, please contact your local department of

social services.

3. If the minor stops living with you, you are required to notify any

school, health care provider, or health care service plan to which you

have given this affidavit.

4. If you do not have the information requested in item 8 (California

drivers license or I.D.), provide another form of identification such as

your social security number or Medi-Cal number.

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TO SCHOOL OFFICIALS:

1. Section 48204 of the Education Code provides that this affidavit

constitutes a sufficient basis for a determination of residency of the

minor, without the requirement of a guardianship or other custody

order, unless the school district determines from actual facts that

the minor is not living with the caregiver.

2. The school district may require additional reasonable evidence that

the caregiver lives at the address provided in item 4.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SER-

VICE PLANS:

1. No person who acts in good faith reliance upon a caregiver’s au-

thorization affidavit to provide medical or dental care, without actu-

al knowledge of facts contrary to those stated on the affidavit, is

subject to criminal liability or to civil liability to any person, or is

subject to professional disciplinary action, for such reliance if the

applicable portions of the form are completed.

2. This affidavit does not confer dependency for health care coverage

purposes.

If you have questions, please contact

Public Counsel’s Children’s Rights Project at

(213) 385-2977 Ext. 500 OR

(800) 870-8090 x500

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Appendix C

I ____________________, am the parent of the following child(ren),

and legally entitled to grant this authorization.

Child’s Name:______________ Child’s Name:___________

Date of Birth: ______________ Date of Birth: ___________

Child’s Name:______________ Child’s Name:___________

Date of Birth: ______________ Date of Birth: ___________

I grant authority, limited to the below defined powers, over the above

child(ren) to:

Name of person granted authorization: ______________________

Address: ___________________________________________

Name of person granted authorization: ______________________

Address: ___________________________________________

The powers granted to ________________________ are the follow-

ing (check and initial):

To authorize medical and dental care for the above child(ren), in-

cluding but not limited to medical examinations, x-rays, tests, surgi-

cal operations, hospital care, or other treatments that are needed or

useful for my child. Such medical treatments that are needed or use-

ful for my child. Such medical treatment shall only be provided upon

the advise of and supervision by a physician, surgeon, dentist, or oth-

er medical practitioner licensed to practice in the United States;

To provide food and shelter for the above– named child(ren), and to

make decisions regarding their day-to-day activities;

To enroll the child(ren) in school and/or daycare and make educa-

tional decisions, including authority to consent to school-related ac-

tivities and field trips;

To transport the child(ren), including authorization to pick the child

up from school or daycare;

CHILD CARE AUTHORIZATION

29

Other powers granted (for example in you want the caretaker to have

authority to take the child(ren) out of state, write that here):

Check one:

This grant of authority is effective as of __________ and shall re-

main in effect until terminated by the undersigned parent or guardi-

an.

This grant of authority shall be valid for the following time period:

From ___________, 20__ until ___________, 20__ .

Parent/Guardian’s signature: _______________ Date: _________

Parent/Guardian’s signature: _______________ Date: _________

State of California

County of ____________________________

On _________________________ before me,

_________________ (insert name and title of the officer) personally

appeared _____________,

who proved to me on the basis of satisfactory evidence to be the person

(s) whose name(s) is/are subscribed to the within instrument and

acknowledged to me that he/she/they executed the same in his/her/their

authorized capacity(ies), and that by his/her/their signature(s) on the

instrument the person(s), or the entity upon behalf of which the person

(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of

California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature ______________________________ (Seal)

If you would like the Child Care Authorization notarized,

please include the wording below.

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Notes:

31

Public Counsel is the nation’s largest pro bono law firm. Public Counsel

coordinates the contributions of thousands of volunteer lawyers each

year. Public Counsel serves those in need — such as children and the el-

derly, literacy projects and low income housing providers, refugees and

the homeless — by providing legal representation and matching financial-

ly eligible clients with volunteer attorneys.

While this publication is designed to provide accurate and current infor-

mation about the law, readers should contact an attorney or other expert

for advice in particular cases, and should also consult the relevant stat-

utes and court decisions when relying on cited materials.

The contents of this brochure may be reprinted. Any adaptation or trans-

lation of the contents of this brochure must be authorized by Public

Counsel.

You may find this booklet and other Public Counsel booklets at

www.publiccounsel.org/practice_areas/childrens_rights. Click

on the “Publications” tab.

© 2016 Public Counsel. All Rights Reserved.

MORE INFORMATION

32

Are you….

A non-parent caring for a child and you need help getting legal

guardianship (custody) .

Already a legal guardian of a child through Probate Court, and you

want to end the guardianship.

A parent whose child is in a legal guardianship and you want to end

the guardianship.

A parent who got a notice saying someone wants to become your

child’s guardian, and you want to object.

A parent, relative or family friend who wants visitation with a child

in guardianship.

We are here to help.

Fall 2016