ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

JV-448

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

                 TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CHILD'S NAME:

ORDER GRANTING AUTHORITY TO CONSENT TO MEDICAL,
SURGICAL, AND DENTAL CARE
(Welf. & Inst. Code, § 366.27)

CASE NUMBER:

1.  The child is a dependent of the court under Welfare and Institutions Code, section 300.

2.  The child is placed by order of this court with a relative caretaker (specify name):

3.  The relative caretaker named in item 2 is granted the authority to provide legal consent for the child's medical, surgical, and 
     dental care. The authority granted by this order is the authority that is held by a parent with full legal custody of a child.

Date:                                                                                                       

JUDICIAL OFFICER 

4.  CERTIFICATION
     I certify that this document is a correct copy of 
     the original on file in my office and that this order
     has not been revoked, annulled, or set aside
     and is still in full force and effect.

Date:

(SEAL)

Clerk, by

, Deputy 

Form Approved for Optional Use 
Judicial Council of California 
JV-448 [New January 1, 2006]

ORDER GRANTING AUTHORITY TO CONSENT TO MEDICAL,
SURGICAL, AND DENTAL CARE
(Welf. & Inst. Code, § 366.27)

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Welfare and Institutions Code, § 366.27 
www.courtinfo.ca.gov