THE STATE OF ______ |
COUNTY OF ______ |
AFFIDAVIT |
Before me, the undersigned authority, personally appeared ______ (relative caregiver), who, being by me duly sworn, deposed as follows: |
My name is ______, and I am of sound mind and am over eighteen (18) years of age. My date of birth, address, contact information, and driver's license or identification card numbers are ______. I am competent to testify to the following facts and matters: |
I am a relative caregiver to ______ (name of child), whose date of birth is ______. My relationship to the child is ______. The above-mentioned child is living with me at ______ (address) because of the following ______ (description of reasons why child lives with relative caregiver and any attempts that the relative caregiver has made to advise the parent of the relative caregiver's intent to consent to medical treatment or educational services for the child, and any response to the relative caregiver provided by the parent). The contact information for the parent is ______ (if known). |
(If applicable) Attached is a signed and dated delegation of authority to me by the parent to consent to educational services or medical treatment. |
(If applicable) The reason why I am unable to contact the parent to advise the parent of my intent to consent to medical treatment or educational services for the child is ______ |
Affiant |
In witness whereof I have hereunto subscribed my name and affixed my official seal this ______ day of ______, 20______. |
______ |
(Signed) |
(Seal) |
§ 431.058, RSMo