Caregiver Consent Form

A document that lets a parent or legal guardian formally authorize a caregiver to look after a minor for a specific period of time.

Use this template

Child's Full Name

Parent/Legal Guardian Name

First Name

Last Name

Caregiver Name

First Name

Last Name

I do not authorize and give my consent to the caregiver on the following:

Location Where Care Will Take Place

From

To

Phone Number

Email

Address

Street Address

City

State / Province

ZIP / Postal Code

Acknowledgement Statement

Parent/Legal Guardian Name

First Name

Last Name

Parent/Legal Guardian Signature

Sign here

Date Signed

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