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SENATE DOCKET, NO. 1099 FILED ON: 1/15/2025
SENATE . . . . . . . . . . . . . . No. 1133
The Commonwealth of Massachusetts
_________________
PRESENTED BY:
Patricia D. Jehlen
_________________
To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:
The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
An Act relative to caregiver authorization affidavits.
_______________
PETITION OF:
NAME:DISTRICT/ADDRESS :Patricia D. JehlenSecond Middlesex 1 of 13
SENATE DOCKET, NO. 1099 FILED ON: 1/15/2025
SENATE . . . . . . . . . . . . . . No. 1133
By Ms. Jehlen, a petition (accompanied by bill, Senate, No. 1133) of Patricia D. Jehlen for
legislation relative to caregiver authorization affidavits. The Judiciary.
[SIMILAR MATTER FILED IN PREVIOUS SESSION
SEE SENATE, NO. 1010 OF 2023-2024.]
The Commonwealth of Massachusetts
_______________
In the One Hundred and Ninety-Fourth General Court
(2025-2026)
_______________
An Act relative to caregiver authorization affidavits.
Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
of the same, as follows:
1 SECTION 1. Section 1 of Chapter 201F, as appearing in the 2022 Official Edition, is
2hereby amended by striking out, in line 7, the words “with whom a minor resides.” and inserting
3in place thereof:-
4 who has been so designated by an authorizing party in an affidavit pursuant to this
5chapter.
6 SECTION 2. Section 2 of Chapter 201F, as appearing in the 2022 Official Edition, is
7hereby amended by striking out the first paragraph and inserting in the place thereof the
8following paragraph:-
9 A parent, legal guardian or legal custodian of one of more minor children, by a caregiver
10authorization affidavit, may authorize a designated caregiver to exercise certain concurrent 2 of 13
11parental rights and responsibilities relative to any designated minor child's education, health care,
12recreational and enrichment activities as described in section 3(b). If a conflicting decision is
13made under these concurrent rights and responsibilities, the decision of the authorizing party
14shall supersede the decision of the caregiver.
15 SECTION 3. Said chapter 201F is hereby further amended by striking out section 3, as
16appearing in the 2022 Official Edition, and inserting in the place thereof the following section:-
17 Section 3.
18 (a) A caregiver shall reside with the minor child or children during the time the caregiver
19is authorized to act relative to said child or children.
20 (b) Under a caregiver authorization affidavit, a caregiver may:
21 (1) give consent to medical, surgical, dental, developmental, mental health or other
22treatment for the minor under the supervision of or upon the advice of a health care professional
23licensed to practice in the commonwealth;
24 (2) exercise parental rights to obtain records and other information with regard to health
25care services and insurance provided to the minor;
26 (3) make educational decisions (including daycare) on behalf of the minor and in all other
27ways stand in for the authorizing party with respect to federal, state and district educational
28policy, including, but not limited to, accessing the minor's educational records, representing the
29minor in enrollment, disciplinary, curricular, special education or other educational matters,
30signing permission slips for school activities and any other decision that facilitates the minor's
31educational experience; 3 of 13
32 (4) make decisions on behalf of the minor regarding recreational and enrichment
33activities including, but not limited to, enrollment, signing permission slips for sports, clubs,
34lessons, camps, and activities and any other recreational and enrichment activities.
35 (5) apply for health insurance and dental insurance coverage for the minor; services and
36support for disabilities; and any other public or private services to address the education or health
37needs of the minor.
38 SECTION 4. Section 4 of Chapter 201F, as appearing in the 2022 Official Edition, is
39hereby amended by inserting, in line 1, after the words “relies on a caregiver” the following
40words:- or alternate caregiver
41 SECTION 5. Said chapter 201F is hereby further amended by striking out section 5, as
42appearing in the 2022 Official Edition, and inserting in the place thereof the following section:-
43 Section 5. The caregiver (and alternate caregiver, if any) authorization affidavit shall
44include the following information: —
45 (1) the name, address and telephone number of the parent, legal guardian or legal
46custodian;
47 (2) the name, address and telephone number of the caregiver;
48 (3) the name, address and telephone number of the alternate caregiver, if any;
49 (4) the name and date of birth of the minor;
50 (5) the relationship of the caregiver(s) to the minor; 4 of 13
51 (6) a statement by the authorizing party that there are no court orders in effect which
52would prohibit the authorizing party from exercising or conferring the rights and responsibilities
53sought to be conferred upon the caregiver or alternate;
54 (7) a statement of the authority being conferred and of any prohibitions;
55 (8) a statement that the affidavit is not for the purposes of circumventing any state or
56federal law, for the purposes of attendance at a particular school, or to re-confer rights to a
57caregiver from whom those rights have been removed by a court of law; and
58 (9) a statement by the authorizing party of when the authority of the appointed caregiver
59commences and when it ends (if specified).
60 The affidavit shall be signed under the pains and penalties of perjury by the authorizing
61party in the presence of 2 adult witnesses, neither of whom may be the caregiver nor alternate
62caregiver, and the affidavit shall be notarized. The affidavit also shall be signed by the caregiver,
63and by the alternate caregiver, if any, who shall attest to being an adult with whom the minor
64resides or will reside.
65 The caregiver authorization affidavit shall be valid for up to 2 years from the date that it
66comes into effect unless a shorter time is specified, and may be reauthorized. The authorizing
67party may reauthorize, amend or revoke the caregiver authorization affidavit by notifying the
68caregiver in writing. The authorizing party shall provide the amended affidavit or revocation to
69all parties to whom he has provided the original affidavit. The caregiver shall provide the
70amended affidavit or revocation to all parties to whom he has provided the original affidavit
71prior to further exercising any rights or responsibilities under the affidavit. 5 of 13
72 SECTION 6: Said chapter 201F is hereby further amended by striking out section 6, as
73appearing in the 2022 Official Edition, and inserting in the place thereof the following section:-
74 Section 6. The caregiver authorization affidavit shall be substantially in the following
75form, except that the use of alternative language consistent with the statute shall not be
76precluded:
77 Caregiver Authorization Affidavit
78 I. What this form enables: A parent, legal guardian or legal custodian of a minor, by this
79affidavit, may authorize a designated caregiver, who is an adult with whom the minor child
80resides or will reside, to exercise certain concurrent parental rights and responsibilities relative to
81a designated minor's education, health care, and recreational and enrichment activities. If a
82conflicting decision is made under these concurrent rights and responsibilities, the decision of the
83authorizing party or a legal guardian or legal custodian appointed subsequent to the execution of
84the affidavit shall supersede the decision of the caregiver.
85 The caregiver authorization affidavit shall only authorize those rights and responsibilities
86that the authorizing party possesses and shall not divest the authorizing party of his rights or
87responsibilities.
88 Under a caregiver authorization affidavit, a caregiver may:
89 (1) consent to medical, surgical, dental, developmental, mental health or other treatment
90for the minor under the supervision or upon the advice of a health care professional licensed to
91practice in the commonwealth; 6 of 13
92 (2) exercise parental rights to obtain records and other information with regard to health
93care services and insurance provided to the minor; and
94 (3) make educational decisions (including daycare) on behalf of the minor and in all other
95ways stand in for the authorizing party with respect to federal, state and district educational
96policy, including, but not limited to, accessing the minor's educational records, representing the
97minor in enrollment, disciplinary, curricular, special education or other educational matters,
98signing permission slips for school activities and any other decision that facilitates the minor's
99educational experience; and
100 (4) make decisions on behalf of the minor regarding recreational and enrichment
101activities including, but not limited to, enrollment, signing permission slips for sports, clubs,
102lessons, camps and activities, and any other recreational and enrichment activities; and
103 (5) apply for health insurance and dental insurance coverage for the minor; for services
104and support for disabilities; and for any other public or private services to address the education
105or health needs of the minor.
106 II. Steps to authorize caregiver rights and responsibilities:
107 1. AUTHORIZING PARTY
108 I, [name of authorizing party], residing at [address of authorizing party] am the
109parent/legal guardian/legal custodian of the minor child(ren) listed below.
110 I, [name of parent or legal guardian or legal custodian], do hereby authorize [name of
111caregiver], residing at [address of caregiver], to exercise concurrently the rights and 7 of 13
112responsibilities, except those prohibited below, that I possess relative to the education, health
113care, recreational and enrichment activities of the minor child(ren) listed:
114 Minor Child's/Children Name(s) Date(s) of Birth
115 ___ ___
116 ___ ___
117 ___ ___
118 The caregiver may NOT:
119 (Please list specifically any education, health care, recreational, or enrichment rights and
120responsibilities that you do NOT wish to confer upon the caregiver.)
121 In the event the above-named caregiver is unavailable or unwilling to serve as caregiver,
122I do hereby authorize [name of alternate caregiver] residing at [address of alternate caregiver], to
123exercise the rights referenced above. (This section is optional)
124 There are no court orders in effect that would prohibit me from exercising or conferring
125the rights and responsibilities that I wish to confer upon the caregiver. (If you are the legal
126guardian or custodian, attach the court order.)
127 I am not using this affidavit to circumvent any state or federal law, for the purposes of
128attendance at a particular school, or to re-confer rights to a caregiver from whom those rights
129have been removed by a court of law. 8 of 13
130 I confer these rights and responsibilities freely and knowingly in order to provide for the
131child(ren) named herein, and not as a result of pressure, threats or payments by any person or
132agency.
133 I understand that, if the affidavit is amended or revoked, I must provide the amended
134affidavit or revocation to all parties to whom I have provided this affidavit.
135 The authority of the caregiver shall commence upon (choose one):
136 a date certain __________; or
137 the date of the incapacity of the authorizing party to make or carry out day-to-day
138decisions concerning the minor, as established by written certification of a licensed physician, or
139the date of the unavailability of the authorizing party to make or carry out day-to-day decisions
140concerning the minor due to circumstances such as, but not limited to, incarceration, voluntary or
141involuntary commitment to a treatment program, detention, deportation, or active military duty,
142as established by attestation of the named caregiver.
143 This document shall remain in effect until (choose one):
144 a date certain (up to two years hence) ________; or
145 two years from the date of the incapacity of the authorizing party to make or carry out
146day-to-day decisions concerning the minor, as established by written certification of a licensed
147physician, or the date of the unavailability of the authorizing party to make or carry out day-to-
148day decisions concerning the minor due to circumstances such as, but not limited to,
149incarceration, voluntary or involuntary commitment to a treatment program, detention,
150deportation, or active military duty, as established by attestation of the named caregiver. 9 of 13
151 unless or until I, as authorizing party, notify the caregiver (and alternate caregiver, if
152any), in writing that I have amended or revoked it, or until such time as the minor child(ren)
153reach the age of majority.
154 I hereby affirm that the above statements are true, under pains and penalties of perjury.
155 Signature:
156 Printed name:
157 Telephone number:
158 2. WITNESSES TO AUTHORIZING PARTY SIGNATURE
159 (To be signed by persons over the age of 18 who are not the designated caregiver or
160alternate caregiver.)
161 Witness No. 1 signature:
162 Witness No. 1 printed name and address:
163 Witness No. 2 signature:
164 Witness No. 2 printed name and address:
165 3. NOTARIZATION OF AUTHORIZING PARTY SIGNATURE
166 On this [date] before me, the undersigned notary public, personally appeared [name of
167authorizing party, and alternate caregiver, if any], proved to me through satisfactory evidence of
168identification, which was [driver's license, etc.], to be the person(s) signing the preceding 10 of 13
169document, and swore under the pains and penalties of perjury that the foregoing statements are
170true.
171 Signature and seal of notary:
172 Printed name of notary:
173 My commission expires:
174 4. CAREGIVER ACKNOWLEDGEMENT
175 I, [name of caregiver], am at least 18 years of age and the named minor child(ren)
176currently reside or will reside with me at [address of caregiver]. I am [relationship to the minors].
177 I understand that I may, without obtaining further consent from a parent, legal custodian
178or legal guardian of the minor child(ren), exercise concurrent rights and responsibilities relative
179to the education and health care of the minor child(ren), except those rights and responsibilities
180prohibited above.
181 I understand that I may not knowingly make a decision which conflicts with the decision
182of the child(ren)'s parent, legal guardian or legal custodian.
183 I understand that, if the affidavit is amended or revoked, I must provide the amended
184affidavit or revocation to all parties to whom I have provided this affidavit prior to further
185exercising any rights or responsibilities under the affidavit.
186 I understand that, if I become unable to carry out the responsibilities conferred by this
187affidavit, I will do so by immediately notifying the authorizing party and the alternate caregiver
188in writing. 11 of 13
189 I hereby affirm that the above statements are true, under pains and penalties of perjury.
190 Signature of caregiver:
191 Printed name:
192 Telephone Number:
193 5. ALTERNATE CAREGIVER ACKNOWLEDGEMENT (This section is optional)
194 I, [name of alternate caregiver], am at least 18 years of age and the child(ren) currently
195reside or will reside with me at [address of caregiver]. I am [relationship to the minor].
196 I understand that I may, in the case of inability or incapacity of the first designated
197caregiver to carry out the responsibilities conferred herein, and without obtaining further consent
198from a parent, legal custodian or legal guardian of the child(ren), exercise concurrent rights and
199responsibilities relative to the education and health care of the child(ren), except those rights and
200responsibilities prohibited above.
201 I understand that I may not knowingly make a decision that conflicts with the decision of
202the child(ren)'s parent, legal guardian or legal custodian.
203 I understand that, if the affidavit is amended or revoked, I must provide the amended
204affidavit or revocation to all parties to whom I have provided this affidavit prior to further
205exercising any rights or responsibilities under the affidavit.
206 I hereby affirm that the above statements are true, under pains and penalties of perjury.
207 Signature of caregiver: 12 of 13
208 Printed name:
209 Telephone Number:
210 6. ATTESTATION OF CAREGIVER AS TO AUTHORIZING PARTY’S
211UNAVAILABILITY<\/ul> (This section is optional)
212 I, [name of caregiver], attest that the authorizing party is unavailable due to
213___________________
214______________________________________________________________________________
215_.
216 I hereby affirm that the above statements are true, under pains and penalties of perjury.
217 Signature of caregiver:
218 Printed name:
219 Telephone Number:
220 7. ATTESTATION OF ALTERNATE CAREGIVER AS TO DESIGNATED
221CAREGIVER’S UNAVAILABILITY (This section is optional)
222 I, [name of alternate caregiver], attest that the designated caregiver is unavailable due to
223______________________________________________________________________________
224______.
225 I hereby affirm that the above statements are true, under pains and penalties of perjury.
226 Signature of alternate caregiver: 13 of 13
227 Printed name:
228 Telephone Number:
229 III. Explanations: This caregiver authorization affidavit is pursuant to chapter 201F of the
230General Laws. A dispute arising hereunder shall be the exclusive jurisdiction of the probate
231courts pursuant to section 3 of chapter 215 of the General Laws.
232 A person who relies on a caregiver authorization affidavit that is consistent with the
233requirements of said chapter 201F has no obligation to make any further inquiry or investigation
234and shall not incur any criminal or civil liability or be subject to professional discipline for doing
235so, unless he knows facts contrary to the affidavit or knows that an authorizing party has made a
236decision to supersede the caregiver's decision. The reliance on the affidavit shall not relieve a
237person from liability arising from other provisions of the law.