Affidavit For Consent For Health Care For A Minor (Page 3 of 4) in pdf

Affidavit for Consent for Health Care for a Minor

State of West Virginia, County of ____________________________________________________

name of county where you are physically located at the time you sign the document

After being duly sworn, I _________________________________ provide the following information:

Adult Caregiver’s Name

A. 1. My full name is ___________________________________________;

Adult Caregiver’s Name

2. My current address is ________________________________________________________________;

Adult Caregiver’s Address

3. My birthdate is _________________________________;

Adult Caregiver’s Birthdate

4. _______________________________, was born on __________________________________

Child’s Name

Child’s Birthdate

5a. _______________________, has resided with me continuously since ________________________,

Child’s Name

Date Child Came to Live with You

a period exceeding six months;

5b. I am related to _____________________________ in the following manner:

Child’s Name

 sibling

 paternal grandparent or

 maternal grandparent or

great-grandparent;

 paternal aunt or uncle;

great-grandparent;

 maternal aunt or uncle;

 paternal cousin;

 maternal cousin;

Note: The person signing this affidavit must truthfully select either 5A or 5B to qualify under the provisions of this law.

6. The names of child’s parents or legal guardians are ______________________________________.

7. The addresses of child’s parents/guardians are __________________________________________

________________________________________________________________________________.

B. I have attempted to obtain the consent of ___________________________________ for medical care for

Parents/Guardians of Child

__________________________________ but I have been unable to do so.

Child’s Name

C. Here are the attempts I have made to obtain the legal guardian/parent or parents’ consent for medical

care for _________________________________________:

Child’s Name

__________________________________________________________________________________

D. To the best of my knowledge the guardian/parents of __________________________________ have not

Child’s Name

refused to give their consent for this medical care.

Affidavit For Consent For Health Care For A Minor Page 3