EDUCATIONAL AUTHORIZATION AFFIDAVIT
Cut Bank School District
The completion and signing of the affidavit before a notary public are sufficient to authorize educational enrollment and services and school-related medical care for the named child. Please print clearly.
The child named below lives in my home, and I am eighteen (18) years of age or older.
Name of child: ______________________________________________
Child’s date of birth: _________________________________________
My name (caretaker relative): __________________________________
My date and year of birth: _____________________________________
My home address: ___________________________________________
My relationship to the child: ___________________________________
(The caretaker relative must be an individual related by blood, marriage, or adoption by another individual to the child whose care is undertaken by the caretaker relative, but who is not a parent, foster parent, stepparent, or legal guardian of the child.)
I hereby certify that this affidavit is not being used for the purpose of circumventing school residency laws, to take advantage of a particular academic program or athletic activity, or for an otherwise unlawful purpose.
o The child was subject to formal disciplinary action, including suspension or expulsion, at the child’s previous school. The school may either implement the previous school district’s disciplinary action without further due process or hold a hearing and determine whether the student’s conduct in the previous school district merits denial of enrollment. If the district decides to enroll the child, then the school may require the child to comply with a behavior contract as a condition of enrollment.
Check the following if true (all must be checked for this affidavit to apply):
o A parent of the child identified above has left the child with me and has expressed no definite time period when the parent will return for the child.
o The child is now residing with me on a full-time basis.
o No adequate provision, such as appointment of a legal custodian or guardian or execution of a notarized power of attorney, has been made for enrollment of the child in school, other educational services, or educationally related medical services.
DO NOT SIGN THIS FORM IF ANY OF THE ABOVE STATEMENTS ARE INCORRECT, OR YOU WILL BE COMMITTING A CRIME PUNISHABLE BY A FINE, IMPRISONMENT, OR BOTH.
I declare under penalty of false swearing under the laws of Montana that the foregoing is true and correct.
Signed this _____ day of ________________, 20__.
(Signature of caretaker relative)
STATE OF MONTANA )
County of _______________ )
On this _____ day of ________________, 20___, before me, a Notary Public for the state of Montana, personally appeared ___________________________________, known to me to be the person named in the foregoing Educational Authorization Affidavit, and acknowledged to me that _____ executed the same as _____ free act and deed for the purposes therein mentioned.
IN WITNESS THEREOF, I have hereunto set my hand and affixed my notarial seal the day and year in this certificate first above written.
(SEAL) NOTARY PUBLIC for the state of Montana
Residing at _______________________, Montana
My commission expires: ____________________
4. If the child stops living with you, you shall notify anyone to whom you have given this affidavit.