Mass. Gen. Laws ch. 201F, sec. 5 — MA Code / Part II / Title II / Chapter 201F / Section 5
Content of affidavit
Status: in_force

Section 5. The caregiver authorization affidavit shall include the following information:— (1) the name, address and telephone number of the parent, legal guardian or legal custodian; (2) the name, address and telephone number of the caregiver; (3) the name and date of birth of the minor; (4) the relationship of the caregiver to the minor; (5) a statement by the authorizing party that there are no court orders in effect that would prohibit him from exercising or conferring the rights and responsibilities that he seeks to confer upon the caregiver; (6) a statement of the authority being conferred and of any prohibitions; and (7) a statement that the affidavit is not for the purposes of circumventing any state or federal law, for the purposes of attendance at a particular school, or to re-confer rights to a caregiver from whom those rights have been removed by a court of law. The affidavit shall be signed under the pains and penalties of perjury by the authorizing party in the presence of 2 adult witnesses, neither of whom may be the caregiver and the affidavit shall be notarized. The affidavit also shall be signed by the caregiver, who shall attest to being an adult with whom the minor resides. The caregiver authorization affidavit may be valid for up to 2 years and may be reauthorized. The authorizing party may reauthorize, amend or revoke the caregiver authorization affidavit by notifying the caregiver in writing. The authorizing party shall provide the amended affidavit or revocation to all parties to whom he has provided the original affidavit. The caregiver shall provide the amended affidavit or revocation to all parties to whom he has provided the original affidavit prior to further exercising any rights or responsibilities under the affidavit.

Section 5. The caregiver authorization affidavit shall include the following information:—

(1) the name, address and telephone number of the parent, legal guardian or legal custodian;

(2) the name, address and telephone number of the caregiver;

(3) the name and date of birth of the minor;

(4) the relationship of the caregiver to the minor;

(5) a statement by the authorizing party that there are no court orders in effect that would prohibit him from exercising or conferring the rights and responsibilities that he seeks to confer upon the caregiver;

(6) a statement of the authority being conferred and of any prohibitions; and

(7) a statement that the affidavit is not for the purposes of circumventing any state or federal law, for the purposes of attendance at a particular school, or to re-confer rights to a caregiver from whom those rights have been removed by a court of law.

The affidavit shall be signed under the pains and penalties of perjury by the authorizing party in the presence of 2 adult witnesses, neither of whom may be the caregiver and the affidavit shall be notarized. The affidavit also shall be signed by the caregiver, who shall attest to being an adult with whom the minor resides.

The caregiver authorization affidavit may be valid for up to 2 years and may be reauthorized. The authorizing party may reauthorize, amend or revoke the caregiver authorization affidavit by notifying the caregiver in writing. The authorizing party shall provide the amended affidavit or revocation to all parties to whom he has provided the original affidavit. The caregiver shall provide the amended affidavit or revocation to all parties to whom he has provided the original affidavit prior to further exercising any rights or responsibilities under the affidavit.