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AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR
1. I hereby declare that I have legal custody of the above named child.
2. I hereby grant my full permission and consent for the temporary guardian to establish a place of residence for my child, and for my child to reside and travel with said temporary guardian.
3. I hereby grant the temporary guardian my full authorization to make all decisions related to my childís educational, religious, and recreational activities and undertakings.
4. I hereby grant the temporary guardian my full authorization to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the temporary guardian to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
5. This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____.
6. For the duration that the temporary guardian cares for my child, the costs associated with my childís maintenance, living expenses, medical, and dental expenses shall be allocated and paid as follows: ____________________________________________________________.
7. In the event that more than one legal guardian exists, the use of the singular shall incorporate the plural. In the event that more than one temporary guardian is named, the use of the singular shall incorporate the plural.
Under penalty of perjury under the laws of the
state of ______________________, I attest to the truthfulness, accuracy, and
validity of the forgoing statement.
I hereby acknowledge the terms set
forth above and agree to assume responsibility in accordance with those terms.
STATE OF __________________
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