Childcare Authorization Form
I, , the parent of the below described minor(s), and legally
entitled to give this authorization, do grant (caregivers name)
the authority, limited to the below defined powers, over the following children:
The powers granted to (caregiver’s name) and are limited to
To seek medical care for the children, including, but not limited to, visits to doctor and/or
To authorize medical treatment or medical procedures in the event of an emergency situation.
To provide food and shelter for the above named children, and to make decisions regarding
their day-to-day activities.
To transport the children in the caregiver’s car, including authorization to pick the children up
This grant of authority is effective as of
(date), and shall remain in effect
until terminated by the undersigned parent.
This grant of authority is signed this day of , 20 in the County of ,
State of Florida.
Notary Signature and Seal Date
***All signatures must be present to be activated for use at the NTC.***