Caregiver Authorization Affidavit

CAREGIVER AUTHORIZATION AFFIDAVIT

I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY that:

1. I am the parent or lawful guardian of ______, born ______.

2. I authorize ______, of ______, to care for my child and to act on my behalf as follows: ______.

3. This authorization is effective from ______ to ______, unless I revoke it sooner in writing.

4. During this period I can be reached at: ______.

5. 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