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OTHER NAMES Authorization for Eldercare Elder Care Authorization Authorization of Care Elder Care Directive

What is an Elder Care Authorization Form?

An Elder Care Authorization Form is a document that grants a caretaker temporary custody of an older adult who needs elder care.

When to use an Elder Care Authorization Form:

  • You want to designate someone to take care of an elderly adult person.
  • You want to provide specific authority and powers to the caretaker.
  • You want to provide emergency contact information.

Sample Elder Care Authorization Form

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Elder Care Authorization


I, the undersigned , hereby grant:


(the "Caretaker),



the authority to take temporary care of the following adult: . I grant this authority in my capacity as 's . My contact information is as follows:




This grant of temporary authorization to provide elder care shall begin on , and shall remain effective until terminated by the undersigned.


The Caretaker shall have the power to:


Other instructions:

In an emergency situation, please contact the following person:





Phone Number:


If that person is not available, please contact the following alternate choice:





Phone Number:





By: Date:


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