How to Fill Out the Caregiver Authorization Affidavit in Massachusetts

The Four Sections of the Form

The Massachusetts Caregiver Authorization Affidavit — sometimes called "Appendix E" — is a two-page document with four distinct sections. Each one must be completed correctly, or schools and medical offices can refuse it. Here is what goes into each section and the mistakes that trip people up.

Section 1: Authorizing Party Information. The parent, legal guardian, or legal custodian fills this out. They identify themselves, name the child, name the caregiver, and affirm under the penalties of perjury that they have legal authority to grant consent, that no court order prohibits it, and that the form is not being used to game school district residency rules. The parent can also write in specific restrictions — for example, barring the caregiver from consenting to a particular type of surgery.

Section 2: Witness Signatures. Two adult witnesses aged 18 or older must watch the parent sign and then add their own signatures, printed names, and contact information. The critical rule: neither witness can be the caregiver. A bank teller, neighbor, coworker, or another family member who is not the designated caregiver will work.

Section 3: Notarization. A notary public acknowledges the parent's signature and applies their official seal. The notary checks the parent's government-issued photo ID. Notarization does not replace the two witnesses — you need both.

Section 4: Caregiver Acknowledgment. The caregiver signs separately, affirming under perjury penalties that they are at least 18, that the child currently lives with them, and stating their relationship to the child.

Common Execution Mistakes

The most frequent reason a school or doctor rejects the affidavit is a missing witness or a witness who is the caregiver. Massachusetts law requires two non-caregiver witnesses plus notarization — skip either and the form fails.

Other mistakes:

• Leaving the end date blank (the form caps at two years automatically, but some offices get confused by an empty field)
• Having the caregiver witness the parent's signature, then also signing as the caregiver
• Getting notarized but not witnessed, or witnessed but not notarized
• Using a photocopy of the parent's signature instead of an original

Where to Find a Notary

Most banks and credit unions notarize documents free for account holders. UPS Store locations charge a small fee. Some public libraries offer notary services. If the parent is incarcerated, the facility typically has a notary available through the law library or social services department.

After the Form Is Complete

Keep the original in a safe place at home. Make photocopies or scans for every school, doctor's office, dentist, MassHealth, and any other institution that needs to see it. Track where each copy goes — if the affidavit is ever revoked or expires, M.G.L. c. 201F requires you to notify every entity that received a copy.

For a complete walkthrough of the execution process, including a distribution log, renewal reminders, and what to do when the parent is in rehab, prison, or unreachable, see the Massachusetts School and Medical Consent Guide.

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