CAREGIVER Packet for Print Student’s Name

School School Year

INSTRUCTIONS – Please read carefully. The Caregiver Packet must be complete and accurate.

A Caregiver packet must be created annually for a student who does not live with their parent(s) or legal guardian.

A “Caregiver” is an adult with whom a student lives full-time and who accepts responsibility for this student

including educational and school-related medical care decisions. Legal rights for the student remain with the parent

or court-appointed guardian.

To complete a Caregiver packet, collect the 10 documents listed below. Submit them to the TUSD Student

Services department at 300 South C Street, Tustin, CA 92780.

DOCUMENTS PROVIDED IN THIS CAREGIVER PACKET

TO THE TUSTIN UNIFIED SCHOOL DISTRICT ARE SIGNED AND SUBMITTED

UNDER PENALTY OF PERJURY.

1 -- Residency Requirements for Children Living Out of the Home (form A, attached)

2 -- Special Power of Attorney (form B, attached)

3 -- Caregiver’s Authorization Affidavit (form C, attached)

4 – Student’s original Birth Certificate or passport

5 – Student’s Immunization Record

6 – Proof of relationship between student and caregiver (description attached)

7 – Parent’s photo ID (a copy is acceptable if parent is not present)

8 -- Caregiver’s photo ID

9 – Proof of legal possession of property

Current lease or rental agreement (within last 12 months); or

Current mortgage statement (within the last 90 days); or

Current property tax statement (within last 12 months); or

A completed Residence Verification Form (available from TUSD Student Services)

10 – Proof of residency

Current gas, electric or water bill (within the last 90 days); or

Caregiver’s California Driver License or ID with matching address

IMPORTANT NOTICE

The parent(s) or court-appointed guardian may revoke the Caregiver’s Authorization Affidavit or Special Power of

Attorney at any time by written notification to TUSD Student Services at the address above. The Caregiver Packet

must be renewed each school year. The Caregiver is responsible for notifying the student’s school of a change in

residence immediately by providing new residency documents (items 9 and 10 above).

Reviewed and received by:

Printed TUSD Student Services Staff’s Name TUSD Student Services Staff Signature Date

RESIDENCY REQUIREMENTS FOR CHILDREN

LIVING OUT OF THE HOME

California Education Code, Section 48204…. “A pupil shall be deemed to have complied with the residency

requirements for school attendance in a school district, provided he or she is: ……

(a)(5) A pupil who lives in the home of a caregiving adult that is located within the boundaries of that school

district. Execution of an affidavit under penalty of perjury pursuant to Part 1.5 (commencing with Section 6550) of

Division 11 of the Family Code by the caregiving adult shall be a sufficient basis for a determination that the pupil

lives in the caregiver’s home, unless the school district determines from actual facts that the pupil is not living in

the caregiver’s home.”

The Tustin Unified School District interprets the intent of the law to be that a student claiming residence under

E.C. 48204(a)(5) must show evidence of actual, full-time residence in a home within the Tustin Unified School

District. Full-time residence shall be demonstrated by the presence of the student's personal effects in the

established residence, and by the presence of permanent living quarters for the student in the established residence.

Generally, direct relatives are not required to be licensed in order to provide a residence for a student.

For students claiming residence under E.C. 48204(a)(5), all letters, records, documents, permission requests,

discipline contacts and other communications will be directed to the person having daily charge over the student

(i.e., the person named on this form as those providing actual, full-time residence for the student).

Parents/guardians of such a student may obtain copies of communications regarding the student by coming to the

school, in person, and requesting copies of written items, or by discussing issues with the proper school

authorities. Tustin Unified School District schools will not allow absentee parents/guardians to assume

responsibility for day-to-day supervision of a student who is physically living with others, per E.C. 48204(a)(5).

The school will rely on those who supervise students on a daily basis to respond to emergencies and provide

effective discipline, when required.

Persons providing residence for students under E.C. 48204(a)(5) should anticipate one or more home visits during

the course of the school year as a method of verifying compliance with the law. IMPORTANT: Providing false

information regarding actual, full-time residence of a student shall be cause for immediate disenrollment of the

student from the school in which the student has been enrolled, and referral of the student to the school which

his/her actual residence entitles him/her to attend. In addition, any student so disenrolled shall not be permitted to

re-enroll in the same school using E.C. 48204(a)(5) as a basis for residency.

Parent and Caregiver Acknowledgement for: Please print Student’s Name

I have read and understand the District’s residency requirements for children living out of the home. I

agree that the above-named student lives in the home of the caregiver named below, not the parent named

below, and I will comply with the District’s residency requirements.

Printed Parent’s Name Parent’s Signature Date

Printed Caregiver’s Name Caregiver’s Signature Date

Printed TUSD Student Services Staff’s Name TUSD Student Services Staff Signature Date

FORM A

Power of Attorney

Information

WHAT IS A POWER OF ATTORNEY? A Power of Attorney is a legal document in which a parent authorizes another adult to act in the parent’s

place on behalf of the child. A Power of attorney is a “permission slip” which tells others, such as doctors

or teachers, that when a parent’s signature is needed, the other adult has authority to sign in place of a

parent. By signing a Power of Attorney, the parent does not give up any parental rights.

The parent retains all legal rights with a Power of Attorney, the parent shares the authority to make

decisions with a designated adult.

In any Power of Attorney, the parent decides:

Which duties he/she wishes to share with the other adult, and

The length of time that the Power of Attorney will be in effect.

A Power of Attorney can be used for a limited purpose such as taking a child to a specific doctor’s

appointment or registering a child for school. A Power of Attorney can also be used for broad purposes

such as all decisions affecting the child for six month period.

A Power of Attorney remains in full force and effect until this special power of attorney is revoked by

written notice. A Power of Attorney can be revoked by the parent at any time.

WHEN TO USE A POWER OF ATTORNEY Powers of Attorney should be used when:

A parent has left his/her child in the custody of another person and is not able to be contacted

should an emergency arise; or

A child is living in a separate home from his/her parent; or

An adult other than a parent is the child’s main caregiver.

DIRECTION FOR SIGNING A POWER OF ATTORNEY A Power of Attorney must be signed by the parent.

The Caregiver keeps the original Power of Attorney with them as proof of their authority to make

decisions on behalf of a child.

Notarization will strengthen application but is not required.

When a parent has given a Power of Attorney to a primary caregiver of a child, the caregiver should have

the following documents for their records:

1. Original copy of the Power of Attorney (may be notarized)

2. Child’s Birth Certificate

3. Child’s Medicaid or other insurance card

4. Copy of child’s immunization record/health inventory/dental?

Special Power of Attorney

I, , residing at

Parent’s name Parent’s address

City of , County of , State of hereby

appoint , residing at

Appointed caregiver/parent’s agent Appointed caregiver/parent’s agent’s address

City of , County of , State of as my

attorney in fact to act in my capacity to do any and all of the following matters relating to the education of my

child, :

Student’s name

To have rights relative to my child’s education that a parent has under Title 20 (commencing with

Section 1400) of the United States Code, Part 300 of Title 34 (commencing with Section 56000) of

the California Education Code;

To represent my child in matters relating to identification, assessment, instructional planning and

development, educational placement, reviewing and revising the Individualized Education Program,

and in all other matters relating to the provision of a free appropriate public education of my child.

This representation shall include the provision of written consent to the Individualized Education

Program including non-emergency medical services, mental health treatment services, and

occupational or physical therapy services, and to sign any consent relating to the Individual

Education Program.

To act as my agent in other matters relating to the education of my child, including the execution of

all consents and approvals which must be provided by a parent or guardian under applicable

California law, including, but not limited to, provisions of the California Education Code, the

California Code of Regulations, and the policies, regulations, procedures, and practices of the Tustin

Unified School District.

To consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and

hospital care to be rendered to my child under the general or special supervision and upon the advice

of a physician or surgeon licensed under the provisions of the Medical Practice Act or to consent to

an x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be

rendered to my child by a dentist licensed under the provisions of the Dental Practice Act;

To perform all other acts necessary to be done in regard to such powers, as amply and fully to all

intents and purposes as I could do if personally present.

The rights, powers and authority of my attorney in fact to exercise any and all of the rights herein granted

shall commence and be in full force and effect on , 20 ,

and shall remain in full force and effect until this special power of attorney is revoked by written notice.

Printed Parent’s name Date

Parent’s signature

FORM B

CAREGIVER’S AUTHORIZATION AFFIDAVIT

Use of this affidavit is authorized by Part 1.5 (commencing with Section 6550) of Division 11 of the California

Family Code.

INSTRUCTIONS: Completion of items 1-4 and the signing of the affidavit is sufficient to authorize enrollment

of a minor in school and authorize school-related medical care. Completion of items 5-8 is additionally

required to authorize any other medical care. Print clearly. Note! Important information on next page.

The minor named below lives in my home and I am 18 years of age or older.

1. Minor’s legal name: LAST FIRST MIDDLE

2. Minor’s birth date:

3. My name (adult giving authorization): CAREGIVER’S NAME

4. My home address:

CAREGIVER’S ADDRESS

CITY STATE ZIP CODE

5. I am a grandparent, aunt, uncle, or other qualified relative of the minor (see reverse of this page

for a definition of “qualified relative”).

6. Check one or both (for example, if one parent was advised and the other cannot be located):

I have advised the parent(s) or other person(s) having legal custody of the minor of my

intent to authorize medical care, and have received no objection.

I am unable to contact the parent(s) or other person(s) having legal custody of the minor at

this time, to notify them of my intended authorization.

7. My date of birth:

8. My California driver’s license or identification card number:

WARNING:

Do not sign this form if any of the statements above are incorrect, or you will

be committing a crime punishable by a fine, imprisonment, or both.

I declare under penalty of perjury under the laws of the State of California that

the foregoing is true and correct.

Dated: Signed:

NOTICES:

1. This declaration does not affect the rights of the minor’s parents or legal guardian regarding the

care, custody, and control of the minor, and does not mean that the caregiver has legal custody of the

minor.

2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.

3. This affidavit is not valid for more than one year after the date on which it is executed.

NOTE! Important Additional Information for Caregiver’s Authorization Affidavit on next page.

FORM C, page 1

Additional Information for Caregiver’s Authorization Affidavit: ADDITIONAL COMMENTS/INFORMATION ON MINOR 1. The date and reason why the student named below has moved into the caregiver’s residence:

Student’s Name: Date of move:

Reason for move:

2. I hereby agree to assume financial liability for the above named student for whom I am the caregiver.

3. I hereby agree to reimburse the Tustin Unified School District for all cost incurred as a result of false

information.

4. Students attending a school in the Tustin Unified School District under false information shall be

withdrawn from the school/district under the terms and conditions of existing policy.

5. If a student attends school in the Tustin Unified School District under false information and has

participated in CIF athletic activities, the games may be forfeited and the student may be ruled not-eligible

for up to a two-year period.

Caregiver’s signature: Date:

TO CAREGIVERS: 1. “Qualified relative,” for purposes of item 5 on page one of Form C, means a spouse, parent, stepparent,

brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or

any person denoted by the prefix “grand” or “great,” or the spouse of any of the persons specified in this

definition, even after the marriage has been terminated by death or dissolution. See page 3 of Form C.

2. The law may require you, if you are not a relative or a currently licensed foster parent, to obtain a foster

home license in order to care for a minor. If you have any questions, please contact your local department

of social services. Information contained on the “Caregiver Authorization Affidavit” submitted by

individuals who are not ‘qualified relatives’ (as determined on the next page) shall be forwarded to the

Orange County Social Services Agency.

3. If the minor stops living with you, you are required to notify any school, health care provider, or health

care service plan to which you have given this affidavit. The affidavit is invalid after the school, health

care provider, or health care service plan receives notice that the minor no longer lives with you.

4. If you do not have the information requested in item 8 (California driver’s license or I.D.), provide

another form of identification such as your social security number or Medi-Cal number.

TO SCHOOL OFFICIALS: 1. Section 48204 of the Education Code provides that this affidavit constitutes a sufficient basis for a

determination of residency of the minor, without the requirement of a guardianship or other custody order,

unless the school district determines from actual facts that the minor is not living with the caregiver.

2. The school district may require additional reasonable evidence that the caregiver lives at the address

provided in item 4.

TO HEALTH CARE PROVIDERS AND HEALTH CARE SERVICE PLANS: 1. A person who acts in good faith reliance upon a caregiver’s authorization affidavit to provide medical

or dental care, without actual knowledge of facts contrary to those stated on the affidavit, is not subject to

criminal liability or to civil liability to any person, and is not subject to professional disciplinary action, for

that reliance if the applicable portions of the form are completed.

2. This affidavit does not confer dependency for health care coverage purposes.

FORM C, page 2

DOCUMENT(S) REQUIRED FOR DETERMINATION OF

RELATIONSHIP OF A RELATIVE

IF STUDENT IS YOUR… REQUIRED DOCUMENT(S):

Son or Daughter Child’s birth certificate

Brother or Sister Child’s birth certificate and

Your birth certificate

Stepson or Stepdaughter

Child’s birth certificate and

Marriage license of student’s parent and

stepparent (if unrelated stepparent is registering

the student)

Half-brother/sister or Stepbrother/sister

Child’s birth certificate and

Half-brother/sister’s birth certificate (showing

common parent)

Niece or Nephew

Child’s birth certificate and

Birth certificate of mother or father who is related to you and

Your birth certificate

Aunt or Uncle Same as for niece or nephew

First Cousin

Child’s birth certificate and

Birth certificates of the related parents and

Your birth certificate

Grandson or Granddaughter

Child’s birth certificate and

Birth certificates of the student’s parent who is

your son or daughter

Great-grandson or Great granddaughter

Child’s birth certificate and

Birth certificate of the child’s parent who is your grandchild and

Birth certificate of your child

NOTES

1. “Relative” means an adult who is related to the child by blood, adoption, or affinity within the

fifth degree of kinship, including stepparents, stepsiblings, and all relatives whose status is

preceded by the words “great,” “great-great,” or “grand,” or the spouse of any of these persons

even if the marriage was terminated by death or dissolution. Welfare and Institutions Code,

361.3, (c)2

2. If birth certificate(s) is/are not available, baptismal records, or other official church documents,

and/or a passport can be substituted, as long as the substituted documents prove degree of

relationship.

FORM C, page 3