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