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CAREGIVER AUTHORIZATION AFFIDAVIT
I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY that:
I am the parent or lawful guardian of ______, born ______.
I authorize ______, of ______, to care for my child and to act on my behalf as follows: ______.
This authorization is effective from ______ to , unless I revoke it sooner in writing.
During this period I can be reached at: .
I confirm that I have the legal authority to grant this authorization in respect of my child.
I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.
SWORN / DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.
_______________________________ _______________________________
A Commissioner for taking Affidavits Signature of Declarant