Form 46-1

A separate authorization agreement should be prepared for each child. Although chapter 34 of the Texas Family Code permits a parent to enter an authorization agreement with a person with whom the child is placed under a parental child safety placement agreement approved by the Texas Department of Family and Protective Services, this form does not address such a situation, which would undoubt­edly involve the department.

NOTICE: THIS DOCUMENT
CONTAINS SENSITIVE DATA

Authorization Agreement for Adult Caregiver

The parties to this authorization agreement are—

Name of parent:

Address:

[Telephone number/Best way to contact]:

Name of adult caregiver:

Relationship to child:

Address:

[Telephone number/Best way to contact]:

The other parent of the child [is deceased/has had [his/her] parental rights terminated].

The other parent of the child is not a party to this authorization agreement. The follow­ing information is known about the other parent:

Name:

Address:

[Telephone number/Best way to contact]:

The child who is the subject of this authorization agreement is—

Name:

Date of birth:

Sex:

Last three numbers of Social Security number:

The parent[s] authorize[s] the adult caregiver to perform the following acts in regard to the child:

1.to authorize medical, dental, psychological, or surgical treatment and immuniza­tion of the child, including executing any consents or authorizations for the release of infor­mation as required by law relating to the treatment or immunization;

2.to obtain and maintain health insurance coverage for the child and automobile insurance coverage for the child, if appropriate;

3.to enroll the child in a day-care program or preschool or in a public or private ele­mentary or secondary school;

4.to authorize the child to participate in age-appropriate extracurricular, civic, social, or recreational activities, including athletic activities;

5.to authorize the child to obtain a learner’s permit, driver’s license, or state-issued identification card;

6.to authorize employment of the child;

7.to apply for and receive public benefits on behalf of the child;

8.to obtain copies or originals of state-issued personal identification documents for the child, including the child’s birth certificate, and, to the extent authorized under federal law, copies or originals of federally issued personal identification documents for the child, including the child’s Social Security card.

The adult caregiver has been given authorization to perform the functions listed above as a result of a voluntary action of the parent[s], and the adult caregiver has voluntarily assumed the responsibility of performing those functions.

Neither the parent[s] nor the adult caregiver has knowledge that a parent, guardian, cus­todian, licensed child-placing agency, or other authorized agency asserts any claim or author­ity inconsistent with this authorization agreement with regard to actual physical possession or care, custody, or control of the child.

To the best of the [parent’s/parents’] and the adult caregiver’s knowledge, there is no court order or pending suit affecting the parent-child relationship concerning the child; there is no pending litigation in any court concerning custody, possession, or placement of the child or access to or visitation with the child; and a court does not have continuing jurisdiction con­cerning the child.

The court with continuing jurisdiction concerning the child is the [number] Court of [county] County, Texas. In cause number [number in which order was issued or litigation is pending], that court has given written approval for the execution of this authorization agree­ment.

To the best of the [parent’s/parents’] and the adult caregiver’s knowledge, there is no current, valid authorization agreement regarding the child.

This authorization is made in conformance with chapter 34 of the Texas Family Code.

The parent[s] and the adult caregiver understand that each party to this authorization agreement is required by law to immediately provide to each other party information regard­ing any change in the party’s address or contact information.

The parent[s] state[s] that this authorization agreement [is for a term of six months from the date the parties enter into the agreement and renews automatically for six-month terms unless the agreement terminates as described below/expires on [date earlier than six months after the date the parties enter into the agreement]].

The parent[s] further state[s] that this authorization agreement may be terminated before the term of the agreement expires by a court’s entering an order (1) affecting the par­ent-child relationship; (2) concerning custody, possession, or placement of the child; (3) con­cerning access to or visitation with the child; or (4) regarding the appointment of a guardian for the child. If such a court order is entered, the agreement may continue if the court entering the order gives written permission.

The parent[s] further state[s] that this authorization agreement may also be terminated before the term of the agreement expires on written revocation by a party to the agreement if the party (1) gives each party written notice of the revocation; (2) files the written revocation with the clerk of the county in which the child resides, the child resided when the agreement was executed, or the adult caregiver resides; and (3) files the written revocation with the clerk of each court (a) that has continuing, exclusive jurisdiction over the child, (b) in which there is a court order or pending suit affecting the parent-child relationship; (c) in which there is pend­ing litigation concerning custody, possession, or placement of the child or concerning access to or visitation with the child; or (d) that has entered an order regarding the appointment of a guardian for the child. [Include if both parents sign agreement: Either parent may revoke this authorization without the other parent’s consent.]

Warnings and Disclosures

The parties to this authorization agreement acknowledge—

1.that this authorization agreement is an important legal document;

2.that the parent[s] and the adult caregiver must read all of the warnings and disclo­sures before signing this authorization agreement;

3.that the persons signing this authorization agreement are not required to consult an attorney but are advised to do so;

4.that the parent’s rights as a parent may be adversely affected by placing or leaving the parent’s child with another person;

5.that this authorization agreement does not confer on the adult caregiver the rights of a managing or possessory conservator or legal guardian;

6.that a parent who is a party to this authorization agreement may terminate the authorization agreement and resume custody, possession, care, and control of the child on demand and that at any time the parent may request the return of the child;

7.that failure by the adult caregiver to return the child to the parent immediately on request may have criminal and civil consequences;

8.that, under other applicable law, the adult caregiver may be liable for certain expenses relating to the child in the adult caregiver’s care but that the parent still retains the parental obligation to support the child;

9.that, in certain circumstances, this authorization agreement may not be entered into without written permission of the court;

10.that this authorization agreement may be terminated by certain court orders affect­ing the child;

11.that this authorization agreement does not supersede, invalidate, or terminate any prior authorization agreement regarding the child;

12.that this authorization agreement is void if a prior authorization agreement regard­ing the child is in effect and has not expired or been terminated;

13.that, except as provided by section 34.005(a–1) of the Texas Family Code, this authorization agreement is void unless, not later than the tenth day after the authorization agreement is signed, the parties mail to a parent who was not a party to the authorization agreement, to the parent’s last known address, if the parent is living and the parent’s parental rights have not been terminated, one copy of the executed authorization agreement by certi­fied mail, return receipt requested, or international registered mail, return receipt requested, as applicable, and one copy of the executed authorization agreement by first-class mail or inter­national first-class mail, as applicable; and

14.that this authorization agreement does not confer on an adult caregiver of the child the right to authorize the performance of an abortion on the child or the administration of emergency contraception to the child.

   
[Name of parent]

SIGNED under oath before me on ______________________________ by [name of parent].

   
Notary Public, State of Texas

   
[Name of adult caregiver]

SIGNED under oath before me on ______________________________ [name of adult caregiver].

   
Notary Public, State of Texas