Temporary Guardianship Authorization For Care of Minor: Child

Download as rtf, pdf, or txt
Download as rtf, pdf, or txt
You are on page 1of 3

Temporary Guardianship Authorization for Care of Minor

Child
Name: ____________________________________________________________________________________
Permanent address: ________________________________________________________________________
Phone: ______________________________________ Birthdate: ____________________________________

Child’s School or Day Care


(Leave this section blank if your child is not in school or any type of child care program.)
School or day care program: _________________________________________________________
Teacher or day care provider: _______________ Grade (if in school): ___________________________
School or day care address: _________________________________________________________________
_____________________________________________ Phone: _______________________________________

Child’s Doctor, Dentist, and Insurance


Doctor (or HMO): _________________________________________________________________________
Address:__________________________________________________________________________________
_____________________________________________ Phone: _______________________________________
Name of medical insurer/health plan: ________________________________________________________
Policy or medical records number: __________________________________________________________
Phone:_______________________________________

Dentist: ___________________________________________________________________________________
Address: __________________________________________________________________________________
_____________________________________________ Phone: _______________________________________
Name of dental insurer/dental plan: __________________________________________________________
Policy number: ______________________________ Phone: _______________________________________

Parents (or Legal Guardians)


Parent 1
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
________________________________________________________________________________
Home phone: ______________________________________________________________________________
Work phone: ______________________________________________________________________________
Cell phone: __________________________________ Email: _______________________________________

Parent 2
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
www.nolo.com Form 1

Page 1 of 3
________________________________________________________________________________
Home phone: ______________________________________________________________________________
Work phone: ______________________________________________________________________________
Cell phone: __________________________________ Email: _______________________________________

Temporary Guardian
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
________________________________________________________________________________
Home phone: ______________________________________________________________________________
Work phone: ______________________________________________________________________________
Cell phone: __________________________________ Email: _______________________________________

Emergency Contact Information


In case of emergency, if a parent, guardian, or temporary guardian cannot be reached, contact:
Name: ____________________________________________________________________________________
Phone: __________________________________Email: ____________________________________________
Additional contact information: _____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Authorization and Consent of Parent(s) or Legal Guardian(s)


1. I am the parent or legal guardian of, and have legal custody of, the minor child named above. I
authorize my child to live with and travel with the temporary guardian. I give the temporary
guardian permission to care for my child in my place and make decisions pertaining to my child’s
care, including educational, recreational, and religious activities.
2. I give the temporary guardian permission to authorize medical and dental care for my child,
including but not limited to medical examinations, X-rays, tests, anesthesia, surgical operations,
hospital care, or other treatments that, in the temporary guardian’s sole opinion, are needed or
useful for my child. Such medical treatment shall be provided only upon the advice of and
supervision by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the
United States.
3. This authorization shall cover the period from ____________ to _______________________________ .
4. While the temporary guardian cares for my child, the costs of my child’s upkeep, living expenses,
and medical and dental expenses shall be paid as follows: ___________________________________
_ _______________________________________________________________________________________
Parent 1’s signature ________________________________________________________________________
Date ______________________________________________________________________________________
Parent 2’s signature ________________________________________________________________________
www.nolo.com Form 1

Page 2 of 3
Date ______________________________________________________________________________________

Consent of Temporary Guardian


I solemnly affirm that I will assume full responsibility for the minor who will live with me during the
period designated above.
Temporary guardian’s signature: ______________________________________________________
Date: ___________________________________

[OPTIONAL: ATTACH NOTARY CERTIFICATE]

www.nolo.com Form 1

Page 3 of 3

You might also like