Dokiman sa a bay yon moun dwa pou pran desisyon konsènan lekòl ak swen sante pitit ou (yo).

Dokiman sa a bay yon moun dwa pou xxxx desisyon konsènan lekòl ak swen sante pitit ou (yo).

Li ka dire jiska 2 zan.

CAREGIVER AUTHORIZATION AFFIDAVIT

DEKLARASYON XXX XXXXX POU BAY MOUN OTORIZASYON POU BAY SWEN

Massachusetts General Laws Chapter 201F

Lwa Jeneral Massachusetts Chapit 201F

1. AUTHORIZING PARTY (Parent/Guardian/Custodian)

MOUN K AP BAY OTORIZASYON AN (paran/responsab legal/moun ki gen xxxxx la)

I, Paran , residing at 000 Xxxx Xxxxxx, Xxxxxx, XX 00000 ,

Ekri non ak adrès moun ou vle pou xxxx xxxx pitit ou a (yo). Moun sa a rele « moun k ap bay swen an. » Moun sa a xx xxxx desizyon sou lekòl ak swen sante pitit ou (yo).

Mwen , k ap viv nan

am the parent/legal guardian/legal custodian (circle one) of the minor child(ren) listed below.

Se paran/reponsab legal/moun ki gen xxxxx legal (ansèkle youn) timoun minè non li (yo) endike anba a.

I do hereby authorize Xxxxxxx Xxxxx , residing at

Ak deklarasyon sa a mwen otorize, k ap viv nan

000 Xxxx Xxxxxx, Xxxxxx, XX 00000 to exercise concurrently the rights and responsibilities, except those prohibited below, that I possess relative to the education and health care of the minor children whose names and dates of birth are:

pou egzèse an menm tan avè m dwa ak responsablite, eksepte sa ki anba yo se mwen xxxxxx ki ka egzèse yo konsènan timoun minè non ak dat nesans yo se :

Pitit #1 01/01/2010 Pitit #2 01/01/2007

Name/non Date of Birth/Dat nesans Name/non Date of Birth/Dat nesans

edikasyon ak swen sante

Name/non Date of Birth/Dat nesans Name/non Date of Birth/Dat nesans

Ekri nenpòt bagay ou pa vle moun k ap bay swen an fè.

The caregiver may NOT do the following: (If there are any specific acts you do not want the caregiver to perform, please state those acts here.)

Moun k ap bay swen an PA gen dwa xx xxxxx sa yo : (Si gen nenpòt bagay espesifik ou pa vle moun k ap bay swen an fè, tanpri xxxx xxxxx sa yo la a.)

(pa egzanp) moun k ap bay swen an pa ka chanje lekòl pitit mwen.

[OPTIONAL – you can choose an alternate caregiver if you want] In the event that the above- named individual is unavailable or unwilling to serve as the caregiver.

[PA OBLIGATWA– ou ka chwazi yon dezyèm moun k ap bay swen si ou vle] Si moun non li anwo a pa disponib oswa li pa vle sèvi kòm moun k ap bay swen an,.

Si moun ou chwazi pou bay swen an pa xx xxx, ou ka chwazi yon dezyèm moun si ou vle. Ekri non ak adrès yo la a.

I hereby appoint Xxxx Xxxxx, residing at 0000 Xxxxxx Xxxxxx, Xxxxxx, XX 00000, as the alternate caregiver.

Mwen nonmen , k ap viv nan ,

kòm dezyèm moun k ap bay swen an.

Kisa sa vle di ?

• Pa gen okenn tribinal ki te di ou pa xx xxxx desizyon pou pitit ou.

• Ou p ap ranpli fòm sa a pou pitit ou ka ale xxx xxx lekòl diferan, oswa pou bay yon moun k ap bay swen tribinal la te retire yo nan men li dwa

• Pa gen okenn moun k xx xxxx ou siyen fòm sa a

• Si ou chanje fòm sa a xxxx xxxxx otorizasyon an, ou pral bay tout moun ki gen yon kopi yon nouvo fòm.

The following statements are true: (Please read)

Deklarasyon sa yo se verite : (Tanpri li)

• There are no court orders in effect that would prohibit me from exercising or conferring the rights and responsibilities that I wish to confer upon the caregiver. (If you are the legal guardian or custodian, attach the court order appointing you.)

Pa gen okenn lòd tribinal an plas ki t ap entèdi mwen egzèse oswa bay dwa ak responsablite mwen ta renmen bay moun k ap bay swen an. (Si ou se responsab legal oswa se ou ki gen xxxxx timoun nan, atache a dokiman sa lòd tribinal ki nonmen ou a.)

• I am not using this affidavit to circumvent any state or federal law, for the purposes of attendance at a particular school, or to re-confer rights to a caregiver from whom those rights have been removed by a court of law.

Mwen p ap itilize deklarasyon xxx xxxxx xx x xxx kontoune okenn lwa eta oswa lwa federal, pou li ka ale xxx xxx lekòl patikilye, oswa pou rebay yon moun k ap bay swen dwa yo te retire nan men li xxx xxx tribinal.

• I confer these rights and responsibilities freely and knowingly in order to provide for the child(ren) and not as a result of pressure, threats or payments by any person or agency. Mwen bay dwa ak responsablite sa yo libelibè epi ak tout konesans mwen pou xxxx xxxx timoun nan (yo) epi se pa xxxxx okenn moun oswa ajans te mete presyon sou mwen, menase mwen, oswa peye mwen.

• I understand that, if the affidavit is amended or revoked, I must provide the amended affidavit or revocation to all parties to whom I have provided this affidavit.

Mwen konprann, si mwen chanje xxxx xxxxx deklarasyon xxx xxxxx an, mwen dwe bay tout moun mwen te bay deklarasyon xxx xxxxx an xxx kopi sa ki chanje a oswa dokiman ki anile l la.

Moun k ap bay swen an gen dwa pou xxxx desizyon konsènan pitit ou xxxxxx si

ou pa disponib..

Upon my unavailability, the named minor children will be deemed to be residing with the named caregiver

Si mwen pa disponib, yo pral konsidere timoun minè non yo anwo a ap viv ak moun k ap bay swen non li nonmen nan dokiman sa a.

Se ou ki gen dwa deside konbyen tan dokiman an valid - li pa xx xxx plis pase

This document shall remain in effect until 01/01/2019 (not more than two years from date of signing) or until I notify the caregiver in writing that I have amended or revoked it.

Dokiman sa a ap rete an xxxx jiska (pa plis pase de zan apre dat ou siyen li an) oswa jiskaske mwen ekri ajan an yon lèt pou xx xx mwen te chanje xxxx xxxxx li.

Atansyon ! W ap bezwen siyen dokiman

an xxxxx xxx notè piblik.

I hereby affirm that the above statements are true, under pains and penalties of perjury. Mwen konfime deklarasyon yo ki anwo a se verite epi mwen rekonèt ap gen pinisyon ak sanksyon si mwen bay fo enfòmasyon.

Authorizing Party Signature / Siyati moun k ap bay otorizasyon an :

Paran

Mete inisyal ou xxx xxxx paj

Printed name / Xxxx non an ak lèt yo dekole : Paran Telephone number / Nimewo telefòn : 000-000-0000

1. WITNESSES TO AUTHORIZING PARTYSIGNATURE

Atansyon ! De moun majè dwe sèvi kòm temwen lè w ap siyen dokiman epi siyen li la - nou tout dwe siyen xxxxx xxx notè piblik. De moun majè yo pa ka moun k ap bay swen an ak dezyèm moun ou chwazi kòm moun k ap bay swen an.

(To be signed by persons over the age of 18 who are not the designated caregiver)

Witness #1 Witness #2

Witness #1 Signature / Siyati temwen #1 Witness #2 Signature / Siyati temwen #2

Witness #1 Witness #2

Printed Name/ Xxxx non ak lèt yo dekole Printed Name/ Ekri non ak lèt yo

000-000-0000 000-000-0000

Phone Number / Nimewo telefòn Phone Number / Nimewo telefòn

2. NOTARIZATION OF AUTHORIZINGPARTY’SSIGNATURE

OTANTIFIKASYON SIYATI MOUN K AP BAY OTORIZASYON AN

Commonwealth of Massachusetts

Ou menm ak de moun majè yo ap bezwen siyen dokiman an xxxxx xxx notè piblik. N ap bezwen montre notè a xxx xxxx idantite tankou yon paspò oswa lisans.

, ss

On this date, , before me, the undersigned notary public, personally appeared, proved to me through satisfactory evidence of identification, which was

, to be the person whose name is signed on the preceding document, and swore under the pains and penalties of perjury that the foregoing statements are true.

Signatureand seal of notary: Printed name of notary: My commissionexpires:

3. CAREGIVER ACKNOWLEDGMENT (To be completed and signed by the caregiver)

Ekri non ak adrès moun k ap bay swen an.

I, Xxxxxxx Xxxxx , am at least 18 years of age and the above child(xxx) will reside with me at 000 Xxxx Xxxxxx, Xxxxxx, XX 00000 .

Mwen, , gen omwen 18 lane epi

Moun k ap bay swen an konnen dokiman sa a xx xx dwa pou xxxx desizyon sou lekòl ak swen sante pitit ou yo, lè pitit ou yo ap viv ak li. Li pa ka deside xxx xxxxx li konnen ou pa t ap dakò. Si ou chanje oswa ou anile akò sa a, moun k ap bay swen an ap bay tout moun kopi.

Timoun non li (yo) anwo a pral viv ak mwen .

This document shall take effect when the child(ren) is/are residing with me. My attestation of the residence of the child(ren) shall be sufficient evidence of such and presentation of this signed document constitutes my attestation.

Dokiman sa a ap xxxx efè lè timoun nan (yo) ap viv ak mwen. Atestasyon mwen pou rezidans timoun nan dwe sifi kòm prèv rezidans li epi depi mwen prezante dokiman sa a ak siyati yo ladan sa reprezante atestasyon mwen.

I understand that I may, without obtaining further consent from a parent, legal custodian or legal guardian of the child(ren), exercise concurrent rights and responsibilities relative to the education and health care of the child(ren), except those rights and responsibilities prohibited above. However, I may not knowingly make a decision that conflicts with the decision of the child(xxx)’s parent, legal guardian or legal custodian.

Mwen konprann, san mwen pa bezwen jwenn plis konsantman nan men xxx xxxxx, moun ki gen xxxxx legal oswa responsab legal timoun nan (yo) ki ka egzèse an menm tan avè m dwa ak responsablite yo, mwen xx xxxx desizyon konsènan edikasyon ak swen timoun nan (yo), eksepte dwa ak responsablite yo te di mwen pa ka egzèse anwo a. Mwen, mwen pa xx xxxxxxx xxxx xxx desizyon si mwen konnen li t ap kont desizyon paran, responsab legal oswa moun ki gen xxxxx legal timoun nan (yo).

I understand that, if the affidavit is amended or revoked, I must provide the amended affidavit or revocation to all parties to whom I have provided this affidavit prior to further exercising any rights or responsibilities under the affidavit.

Mwen konprann, si yo chanje xxxx xxxxx deklarasyon xxx xxxxx an, mwen dwe bay tout moun mwen te bay deklarasyon xxx xxxxx an xxx kopi sa ki chanje a oswa dokiman ki anile l la avan m ap ka egzèse nenpòt dwa oswa responsablite mwen gen nan deklarasyon xxx xxxxx xx x.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Mwen konfime deklarasyon yo ki anwo a se verite epi mwen rekonèt ap gen pinisyon ak sanksyon si mwen bay fo enfòmasyon.

Moun k ap bay swen an ka siyen menm lè ak ou, xxxx xxx lè diferan. Moun k ap bay swen an pa bezwen siyen xxxxx xxx notè piblik non plis.

Signature of caregiver / Siyati moun k ap bay swen an : Xxxxxxx Xxxxx

Printed name / Non an ekri ak lèt yo dekole : Xxxxxxx Xxxxx Telephone Number / Nimewo telefòn : 000-000-0000

Dat / dat : 06/01/2017

4. ALTERNATE CAREGIVER ACKNOWLEDGMENT (To be completed and signed by the alternate caregiver, if you choose one)

Si ou chwazi yon lòt moun k ap bay swen, oka premye moun nan pa ta disponib,, ekri non ak adrès moun nan.

REKONESANS DEZYÈM MOUN K AP BAY SWEN (Pou dezyèm moun k ap bay swen an ranpli ak siyen, si ou chwazi youn)

I, Xxxx Xxxxx , am at least 18 years of age and the above child(ren) will reside with me at 0000 Xxxxxx Xxxxxx, Xxxxxx, XX 00000 .

Mwen, , gen omwen 18 lane epi

Timoun non li (yo) anwo a pral viv ak mwen .

Moun k ap bay swen an, oka premye moun nan pa ta disponib la, konnen dokiman sa a bay li dwa pou xxxx desizyon sou lekòl ak swen sante pitit ou yo, lè pitit ou yo ap viv ak li. Li pa ka deside xxx xxxxx li konnen ou pa t ap dakò. Si ou chanje oswa ou anile akò sa a, moun k ap bay swen an ap bay tout

moun kopi.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Mwen konfime deklarasyon yo ki anwo a se verite epi mwen rekonèt ap gen pinisyon ak sanksyon si mwen bay fo enfòmasyon.

Moun k ap bay swen an ka siyen menm lè ak ou, xxxx xxx lè diferan. Moun k ap bay swen an pa bezwen siyen xxxxx xxx notè piblik non plis.

Signature of caregiver / Siyati moun k ap bay swen an : Xxxx Xxxxx

Printed name / Non an ekri ak lèt yo dekole : Xxxx Xxxxx Telephone Number / Nimewo telefòn : 000-000-0000

Dat / dat : 06/01/2017

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Dokiman sa a bay yon moun dwa pou pran desisyon konsènan lekòl ak swen sante pitit ou (yo).

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