Pages 1--5 from D6907_351401010403.p65Document Body Page Navigation Panel Pages 1--5 from D6907_351401010403.p65 Page 1 2 RELATIVE CAREGIVERS' SCHOOL AUTHORIZATION AFFIDAVIT This Affidavit is to be completed when a child is registered for school by a relative caregiver who is raising the child without custody or guardianship. ° A "relative" is an adult who, by blood, marriage or adoption, is the child's great grandparent, grandparent, step grandparent, great aunt, aunt, step aunt, great uncle, uncle, step uncle, step parent, brother, sister, step brother, step sister, half brother, half sister, niece, nephew, first cousin or first cousin once removed, but who does not have legal custody or legal guardianship of the child. ° A "relative caregiver" is an adult raising a child who is living with and related to the caregiver through the relationships listed above. ° This Caregivers' School Authorization affidavit is not intended for the school registration of homeless children. Homeless children are to be admitted to school according to Title VII of the McKinney Homeless Education Improvements Act of 1999. Please contact the District Office in your local school district for assistance with completing this affidavit. In accordance with Delaware Law on Education (14 Del. C. §202 (a) ) I swear or affirm that: 1. I, ____________________________ reside at ___________________________________________ , in the (Name of Relative Caregiver) (Address) ___________________________________ School District. (School District) 2. I am eighteen years of age or older. 3. _____________________________ , ___________________ resides with me at this address as a result of: (Name of Child) (Date of Birth) Check the reason( s) that apply: (Parent includes custodian or guardian.) A. _____ the parent is dead, the parent is so sick he/ she cannot care for the child, the parent is in jail, or the parent is on military assignment; B. _____ the parent fails or is unable to provide adequate financial support or parental care or guidance; C. _____ the parent or others in his/ her residence have allegedly abused or neglected the child; D. _____ the parent has a physical or mental condition which prevents adequate care and supervision of the child; E. _____ the student's home is uninhabitable due to loss, damage, or disrepair; F. _____ the parents cannot be located; G. _____ other circumstances as approved by the school district: District Explanation: ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4. By my signature on this Affidavit, I swear or affirm that the student's claim of residency with me as caregiver is not for the purpose of: 1) attending a particular school; 2) circumventing or avoiding the Choice program's decisions; 3) participating in athletics at a particular school; 4) taking advantage of special services or programs offered at a particular school or for any other similar purpose. 5. By my signature on this Affidavit, I swear or affirm that the student is not currently subject to expulsion from school, or suspended from school for conduct that could lead to expulsion. 1 1 Page 2 3 6. By signing this Affidavit, I agree to be responsible for: A) enrolling the student in school; B ) being the legal contact for the school regarding, but not limited to, truancy and discipline; C) making school-based decisions, regarding but not limited to special education; and D) giving medical approval for health care administered by the school. 7. Name of the child's mother, father, legal custodian, or guardian: ____________________________________ 8. If this child is under the care of a custodian or guardian, attach a copy of the portion of the custody order indicating to whom custody or guardianship is granted, if available. 9. If the parent( s), custodian, or guardian is available to sign this affidavit indicating their approval for a relative caregiver to take educational responsibility for their child who is living with that caregiver, this section must be completed and signed. I, (Print your name)_________________________________ , the (Check the appropriate box) parent( s) custodian guardian of (Print child's name)_________________________________ , a minor who is living with this caregiver and is related to me by blood, adoption, or marriage, give permission for (Print caregiver's name) _________________________________ , to stand in my place reguarding educational responsibility for this child. ____________________________________________ __________________________ Signature of Parent( s), Custodian, or Guardian Date 10. Because the parent( s), custodian, or guardian cannot be located, you must complete Section A below as one of the proofs of your efforts to reach the parent( s), custodian, or guardian. In addition, you must also choose one of the Options --B, C, D, or E. It is required that you complete the described action and write the information your option requests. Required Section A: A. I have sent a certified letter/ notice to the parents, guardian, or custodian at their last known address. This letter/ notice informed the parent( s), custodian, or guardian for this child that I intend to act as a caretaker and take educational responsibility for the child. That letter/ notice is attached along with the certified mail receipt reporting the letter was not deliverable because the parent( s), custodian, or guardian of the child was not at this location. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 2 2 Page 3 4 And one of the following options: B. I or a person acting in my behalf, (name) _______________________________________ visited the last known address of the parent( s), custodian, or guardian. Describe what was found at that visit. Include the name of the person spoken to; what that person's relationship with the parent( s), custodian, or guardian is; what the contact person said; and any other related information that clarifies the situation. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ OR C. I or a person acting in my behalf, (name) _______________________________________ attempted to determine the location of the parent( s), custodian, or guardian by contacting their place( s) of employment, health care provider( s), or friends. Describe the results of your inquiry. Include the name of the employers, health care providers, or friends. Tell what was their response to the request for the location of the parent( s), custodian, or guardian. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ OR D. I placed a notice in the News Journal and the Delaware State News informing the parent( s), custodian, or guardian of (child's name) _____________________________________ that I intend to take educational responsibility of the child. Eight days after publication describe what happened. Include the response you received or the lack of response. Attach a copy of the legal notice, being sure to include the portion of the newspaper with the date the notice was printed. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ OR E. Other documents or confirmations that show the parent( s), custodian, or guardian cannot be found. _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 11. I am ___________________________________ to the child for whom this Affidavit is being submitted. (Relationship -see instructions for the acceptable list of relatives) 3 3 Page 4 5 12. I can prove my relationship to this child and also that I am the caregiver to this child by providing one of the proofs listed below from each column. ° There must be two different forms of documentation, one from each column. ° One must show proof of relationship and the other proof of caregiving. These documents, or other similar documents as approved by the school district, must be presented for registration. Check which document you will use from each column. PROOF OF RELATIONSHIP PROOF OF CAREGIVING Birth certificate of caregiver, the adult child, and birth certificate of the child. Medical records where a caregiver is required to give approval, such as shots. Such records must show the relationship between the caregiver and the child. A Will which lists the child and the relationship between the caregiver and child. Insurance for the caregiver or child which includes the relationship between the caregiver and child. A letter from a social worker, lawyer, religious leader, previous school district, licensed medical, mental health, or behavioral professional that verifies the relationship of the child to the caregiver. The National School Lunch Program application. Child is listed as occupant in an apartment or other housing and his/ her relationship to the caregiver is included. Caregiver received Child-only Temporary Aid for Needy Families (TANF) grant for this child. Child claimed on Federal Income Tax return. Caregiver receives Earned Income Tax Credit for the child. Hospital, clinic, Public Health, or Medicaid, or food stamp records showing the relationship between the caregiver and the child. Division of Services for Children, Youth and their Families' records specifying the relationship between the caregiver and child. Military or veterans records which specify relationship Or other documents as approved by the school district. Medical records where a caregiver's authorization to give approval for services such as shots is acceptable. A letter from a social worker, lawyer, religious leader, licensed medical, mental health, or behavioral professional, or neighbor confirming the child is being cared for by the caregiver. Child is listed as occupant in an apartment or other housing and his/ her relationship to the caregiver is included. Caregiver receives Child-only Temporary Aid for Needy Families (TANF) grant for this child. Child claimed on Federal Income Tax return. Caregiver receives Earned Income Tax Credit for the child. Child's Social Security survivor death benefits are received by the caregiver for the child. Hospital, clinic, Public Health, or Medicaid records where a caregiver's authorization to give approval for services such as shots is acceptable. Division of Services for Children, Youth and their Families' records showing that the caregiver is the contact for this child. Or other documents as approved by the school district. 4 4 Page 5 13. To be completed by the relative caregiver: By signing this Relative Caregivers' School Authorization Affidavit, I understand that if I am making false statements I am subject to a minimum civil penalty of $1,000 and maximum of the average annual per student education cost. I may be required to reimburse the school district tuition costs. I may also be subject to criminal prosecution. I, (Print your name)_________________________________ , do declare, certify and state under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge. This, the ________ day of ___________________ , 20 _____. (Date) (Month) (Year) ___________________________________ Signature of Relative Caregiver (To be signed in the Presence of a Notary Public) 14. To be completed by the Notary Public: On this, the ________ day of ___________________ , 20 _____, personally appeared before me, _________________________________ , known to me to be the person described in and who executed the foregoing instrument and he/ she acknowledged that he/ she executed the same and being duly sworn by me, made oath that the statements in the foregoing instrument are true. _____________________________________________ (Printed Name of Notary Public) _____________________________________________ My commission expires _________________________ NOTARY PUBLIC (Signature) (Date) FOR DISTRICT USE ONLY: Approved on: ____________________ (date) by ____________________________________ (position) This Affidavit is in effect on ____________________ (date) . Expiration: ____________________ (date). If disapproved, reason: _________________________________________________________________ District Authorized Signature ____________________________________________________________ Date: ____________________ Appeal to State Board: Yes _________ No _________ Result: ______________________________________ April, 2001 Document Control No.: 35 14 01 01 04 03 5 Page Navigation Panel 1 2 3 4 5