Childcare Authorization Form

This Authorization gives the Authorized Caregiver only the specific permissions described in clauses 3 to 5 below — travel, medical treatment, and school or daycare pickup — for the Child named above and no other child. It gives the Authorized Caregiver no authority beyond what is stated in this document.

This Authorization does not transfer, and does not affect, legal custody or guardianship of the Child. The Parent/Guardian remains the Child's parent or legal guardian for all purposes, with full parental rights and responsibilities, for as long as this Authorization is in effect.

This Authorization takes effect on and continues until , unless the Parent/Guardian revokes it earlier under clause 7. If no fixed end date applies, write 'until revoked' in place of an end date.

The Parent/Guardian authorizes the Authorized Caregiver to travel with the Child within during the period this Authorization is in effect.

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For international travel, many countries, airlines and border authorities require a signed and notarized consent letter from any parent or legal guardian not travelling with the Child, in addition to this Authorization, and some require a specific form of wording. Check the requirements of the departure country, destination country and any transit country well before the trip — this Authorization alone may not be accepted at the border.

The Authorized Caregiver should carry a copy of the Child's birth certificate or passport, proof of the Parent/Guardian's relationship to the Child, and a copy of this Authorization when travelling with the Child.

The Parent/Guardian authorizes the Authorized Caregiver to consent, on the Child's behalf, to emergency medical, dental and surgical examination and treatment that a licensed physician, dentist, hospital or emergency medical provider considers necessary — including ambulance transport — if the Parent/Guardian cannot be reached promptly.

The Parent/Guardian also authorizes the Authorized Caregiver to consent to routine medical and dental care, including check-ups, vaccinations and administering prescribed medication, .

The Parent/Guardian remains responsible for all costs of medical and dental treatment provided to the Child under this clause. The following information is provided for the treating provider:

1. Health insurance provider and policy/member number:

2. Preferred physician and hospital, if any:

3. Known allergies:

4. Current medications and dosages:

5. Other medical conditions the provider should know about:

The Parent/Guardian authorizes the school, daycare, after-school programme or camp the Child attends to release the Child into the care of the Authorized Caregiver named above, and of each additional person listed below, and to share routine attendance and welfare information with them. Each person should be asked to show government-issued photo identification before being allowed to collect the Child.

The following additional people are also authorized to pick up the Child:

1. — relationship to Child: — phone:

2. — relationship to Child: — phone:

If the Authorized Caregiver cannot reach the Parent/Guardian named above in an emergency, the following alternate contacts should be tried, in the order listed:

1. — relationship to Child: — phone:

2. — relationship to Child: — phone:

The Parent/Guardian may revoke this Authorization at any time by giving written notice to the Authorized Caregiver, effective when that notice is delivered. This Authorization also ends automatically on the end date stated in clause 2, if any, or when the Child reaches the age of majority, whichever happens first.

The Authorized Caregiver has no authority under this Authorization once it has been revoked or has ended, even if a copy remains in the Authorized Caregiver's possession.

Some recipients of this Authorization — including airlines, border officials, hospitals, and some schools — may require it to be notarized, apostilled, or accompanied by additional proof of the relationship between the Parent/Guardian and the Child before they rely on it, particularly for international travel or treatment by a provider unfamiliar with the family. Evenseal does not provide notarization; check the specific requirements of the airline, country, hospital or school this Authorization will be presented to, and have it notarized locally if required.

An electronic signature on this Authorization is legally recognized for ordinary purposes in most countries, but it does not, by itself, satisfy a notarization requirement where one applies.

This Authorization is governed by the laws of .

This Authorization is the Parent/Guardian's complete statement of the authority granted to the Authorized Caregiver for the Child, and replaces any earlier authorization the Parent/Guardian gave the Authorized Caregiver for the same purpose. It may only be changed or extended by a new authorization signed by the Parent/Guardian.

This Authorization may be signed electronically, and may be presented as a photocopy or scan — a copy is as valid as the original when shown to a school, medical provider, airline or other third party.