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    Authorization for Temporary Guardianship of Minor

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    Last Updated: February 9, 2023.

    About this Form

    This document is an Authorization for Temporary Guardianship of a Minor. This form is appropriate for use when a parent or legal guardian of a minor child wishes to appoint temporary guardianship to another individual or individuals for a specific period of time. This may occur in a variety of circumstances, such as when the parent or legal guardian is unable to care for the child due to work obligations, travel, illness, or other reasons. The form provides a written record of the arrangement and defines the responsibilities and limitations of the temporary guardian in caring for the child.

    The form collects information about the child, including the child's full legal name, date of birth, age, and gender, as well as information about the child's medical and dental providers. The form also includes information about the child's parents or legal guardians, the temporary guardians, and an emergency contact. The form includes a section in which the parent(s) or legal guardian(s) provide their authorization and consent for the temporary guardianship arrangement. This section includes information about the start and end dates of the guardianship, as well as the allocation of financial responsibility associated with the child's care.

    The parent(s) or legal guardian(s) must sign the form, in addition to the temporary guardians, in which they acknowledge their responsibilities and agree to the terms. Finally, a notary public or other officer must verify the identity of the individuals who will sign the document. They can attach a certificate of acknowledgment or use the one provided within the form.

    Temporary Guardianship vs. Full Guardianship

    Please note that temporary guardianship is distinct from full guardianship. Temporary guardianship refers to a limited and temporary transfer of parental responsibilities to another individual, while full guardianship involves a more permanent transfer of legal custody and control over the child. In some circumstances, a court may need to approve the temporary guardianship arrangement, and in such cases, consulting an attorney may be advisable.

    AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR

    Child
    Full Legal Name: ___________________________________________________________________
    Date of Birth: _______________________ Age: ___________ Gender: ___________


    Doctor's Information
    Doctor's Name: ____________________________________________________________________
    Doctor's Address: __________________________________________________________________
    Doctor's Office Phone: ____________________ Doctor's Emergency Phone: __________________
    Medical Insurer/Health Plan: __________________________ Policy #: ______________________
    Allergies to Medications: ____________________________________________________________
    Allergies (Other): ___________________________________________________________________
    If applicable, please note the conditions for which the child is currently receiving treatment:
    _________________________________________________________________________________
    Note any other significant medical information:
    _________________________________________________________________________________
    _________________________________________________________________________________

    Dentist's Information
    Dentist's Name: ____________________________________________________________________
    Dentist's Address: __________________________________________________________________
    Dentist's Office Phone: ____________________ Dentist's Emergency Phone: _________________
    Dentist's Insurer/Health Plan: __________________________ Policy #: ______________________


    Parent(s)/Legal Guardian(s):

    Parent #1:
    Name: ___________________________________________________________________________
    Address: _________________________________________________________________________
    Home phone: __________________________ Work phone: __________________________
    Cell phone: ____________________________ Pager: _______________________________
    Email: ________________________________
    Additional Contact Information: _______________________________________________________
    _________________________________________________________________________________

    Parent #2:
    Name: ___________________________________________________________________________
    Address: _________________________________________________________________________
    Home phone: __________________________ Work phone: __________________________
    Cell phone: ____________________________ Pager: _______________________________
    Email: ________________________________
    Additional Contact Information: _______________________________________________________
    _________________________________________________________________________________


    Temporary Guardian(s):

    Temporary Guardian #1:
    Name: ___________________________________________________________________________
    Address: _________________________________________________________________________
    Home phone: __________________________ Work phone: __________________________
    Cell phone: ____________________________ Pager: _______________________________
    Email: ________________________________
    Additional Contact Information: _______________________________________________________
    _________________________________________________________________________________

    Temporary Guardian #2:
    Name: ___________________________________________________________________________
    Address: _________________________________________________________________________
    Home phone: __________________________ Work phone: __________________________
    Cell phone: ____________________________ Pager: _______________________________
    Email: ________________________________
    Additional Contact Information: _______________________________________________________
    _________________________________________________________________________________


    Emergency Contact:
    Name: ___________________________________________________________________________
    Address: _________________________________________________________________________
    Home phone: __________________________ Work phone: __________________________
    Cell phone: ____________________________ Pager: _______________________________
    Email: ________________________________
    Additional Contact Information: _______________________________________________________
    _________________________________________________________________________________


    AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

    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 child's 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 child's 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.


    Parent 1's signature: ________________________________ Date: ____________________


    Parent 2's signature: ________________________________ Date: ____________________


    CONSENT OF TEMPORARY GUARDIAN

    I hereby acknowledge the terms set forth above and agree to assume responsibility in accordance with those terms.
    Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy, and validity of the forgoing statement.


    Temporary Guardian 1's signature: ________________________________ Date: ____________________


    Temporary Guardian 2's signature: ________________________________ Date: ____________________


    CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

    A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.


    State of _____________________
    County of ___________________

    On __________________ before me, ________________________________ (here insert name and title of the officer), personally appeared ________________________________ ________________________________ ________________________________ ________________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

    I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct.

    WITNESS my hand and official seal.

     

    ________________________________         (Seal)
    Signature

    Other Forms You May Need

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