Kinship Caregivers Informed Consent Declaration for Minors

Persons authorized to provide informed consent to health care on behalf of a child under the age of 18 must be a member of one of the following classes of persons in the following order of priority:

1)	A guardian or legal custodian appointed by the court;
2)	 A person authorized by the court to consent to medical care for a child in out-of-home placement pursuant to the dependency and termination of parental rights statutes;
3)	Parents of the minor patient;
4)	A person to whom the minor’s parent have given a signed authorization to make health care decisions for the minor patient; and
5)	A competent adult representing himself or herself to be a relative responsible for the health care of such minor patient or a competent adult who has signed and dated a declaration under penalty of perjury stating that the adult person is a relative who is responsible for the health care of the minor patient.

The following declaration applies to a person in category 5 listed above:

I ________________________ am a relative of 	
	(print name)	(print name of minor patient) 

and am responsible for his or her health care.  I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Signed at __________________________	on		
	(place)	(date)

	Signature

	Relationship to minor patient

This declaration is effective for no more than six (6) months from the date on which it is signed.