A relative caregiver affidavit given to a health care provider or school is invalid unless it is signed and contains, at a minimum, the following information: (1) The name of the minor child; (2) The minor childs date of birth; (3) The relative caregivers name and date of birth and the address at which the relative caregiver lives with the minor child; (4) The relationship of the relative caregiver to the minor child; (5) The Oregon driver license or identification card number of the relative caregiver; (6) The contact information of the legal parent or guardian; (7) A description of any attempts that the relative caregiver has made to advise the legal parent or guardian of the relative caregivers intent to consent to medical treatment or educational services for the minor child, and of any response to the relative caregiver provided by the legal parent or guardian; (8) If applicable, the reason why the relative caregiver is unable to contact the legal parent or guardian to advise the legal parent or guardian of the relative caregivers intent to consent to medical treatment or educational services for the minor child; (9) The date the relative caregiver signed the affidavit; and (10) A declaration under penalty of perjury that the named minor child lives with the relative caregiver, that the relative caregiver is a competent adult and 18 years of age or older and that the information provided in the affidavit is true and correct. Note: See note under 109.570.
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