Kentucky Caregiver Affidavit Fillable Form and Template

If you are searching for a fillable Kentucky caregiver affidavit form, the good news is that a free, legally compliant template exists. The bad news is that generic templates sold on sites like Etsy and Gumroad often use California law (Family Code § 6550) instead of Kentucky's statute — and a school registrar in Louisville or Lexington will reject a California form on sight.

Here is where to find the real thing and what it must contain.

The Free Model Affidavit

Kentucky Youth Advocates (kyyouth.org) and the Kinship Families Coalition of Kentucky (kinshipky.org) jointly produced a model Caregiver's Authorization Affidavit after the Kentucky General Assembly passed Senate Bill 176 in 2014. This two-page PDF is:

• Free to download
• Aligned with KRS 405.024 (health care) and KRS 158.144 (school decisions)
• Kentucky law requires schools and healthcare providers to honor a valid affidavit within its scope, subject to statutory exceptions

DCBS used to distribute its own version through internal Standard Operating Procedures, but Memorandum PPM 26-07, effective June 15, 2026, removed that form from the manual. The Kentucky Youth Advocates and Kinship Coalition versions remain the standard community templates.

What a Valid Kentucky Affidavit Must Include

Under KRS 405.024(2), the affidavit must contain specific elements. Any template missing these is legally incomplete:

• Your full legal name, home address, date of birth, and confirmation you are at least 18
• The child's full legal name and date of birth
• A statement that the child resides in your home
• Your specific relative relationship to the child (grandparent, aunt, uncle, adult sibling, cousin, etc.)
• A statement authorizing you to approve or withhold consent for healthcare and school decisions
• Identification of the child's parents, legal guardians, or legal custodians and your relationship to them
• A statement confirming that no other party has legal standing in a custody matter concerning the child
• Dated signatures of the parents or legal custodians approving your authority — or, if they are unavailable, a detailed statement describing what happened and the reasonable efforts you made to locate them
• Mandatory notices that false statements are a Class A misdemeanor and that executing the affidavit does not confer custody or de facto custodian status
• Your signature under penalty of perjury, acknowledged before a notary public

Why Generic Templates Get Rejected

National document platforms market "Minor Child Power of Attorney" packages to Kentucky searchers. The problems:

• They require a parent signature with no pathway for unavailable parents — Kentucky's statute specifically allows the caregiver to execute independently when parents cannot be found
• They omit the statutory liability protection language from KRS 405.024(7)-(8), which is what gives schools and doctors confidence to accept the form
• They use general contract language instead of the specific statutory citations Kentucky institutions expect

A school registrar or clinic intake desk trained on KRS 158.144 will look for those statutory references. A form that cites California Family Code or a generic "Power of Attorney" header raises a flag.

Filling Out the Form

The model template from Kentucky Youth Advocates has labeled fields, but a few sections trip people up:

Parent unavailability statement: If the parent cannot sign, you cannot leave this blank. Describe specifically what happened — parent entered treatment on a certain date, is incarcerated at a particular facility, has not been in contact since a specific time — and list what you did to try to reach them (calls, texts, certified mail, asking family members).

Notarization: The affidavit must be acknowledged before a notary. Kentucky county clerk offices offer free or low-cost notary services. Banks and UPS stores also have notaries, though they may charge a small fee. Do not sign the affidavit before you are in front of the notary — they need to witness your signature.

One per child: Kentucky law requires a separate affidavit for each child. If you are caring for three siblings, you need three executed and notarized documents.

For a complete walkthrough — including the parent-search documentation, the annual renewal process, front-desk scripts for pushback, and a side-by-side comparison of the affidavit versus the power of attorney — the Kentucky School and Medical Consent Guide organizes everything into one toolkit.

See more Kentucky guides →