Temporary Guardianship Authorization for Care of Minor
Child
Name: ______________________________
Permanent address: ________________________________________________________ 
__________________________________________________________________
Home Phone: __________________
Date of Birth: _______________________
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 Child Care Program: _______________________ Grade (if in school): ___
Teacher: _____________________________
Address: _______________________________________ 
Phone: ____________________ 
Other Child Care Program (such as after-school program): ___________________________
Address: _______________________________________ 
Phone: ____________________ 
Responsible Adult: ________________________________
Child’s Doctor, Dentist and Insurance
Doctor (or HMO): ____________________
Address: __________________________________________________________________
__________________________________________________________________
Phone: ____________________
Name of Medical Insurer/Health Plan: __________________________ Policy No. ________
Dentist: ____________________ 
Address: __________________________________________________________________
__________________________________________________________________
Phone: ____________________ 
Name of Dental Insurer/Dental Plan: ___________________________ Policy No. ________
Parents (or Legal Guardians)
Parent 1
Name: _________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________ 	Email: ____________________
Additional contact information: ________________________
Parent 2
Name: _________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
Home phone: ____________________ 	Work phone: ____________________
Cell phone or pager: ____________________ 	Email: ____________________
Additional contact information: ________________________
Temporary Guardian
Name: _________________________________________________
Address: __________________________________________________________________
__________________________________________________________________
Home phone: ____________________ Work phone: ____________________
Cell phone or pager: ____________________ 	Email: ____________________
Relationship to minor: ____________________________
Emergency Contact
In case of emergency, if the temporary guardian cannot be reached, please contact: _______________
Home phone: ____________________	 Work phone: ____________________
Cell phone or pager: ____________________ 	Email: ____________________

Authorization and Consent of Parent(s) or Legal Guardian(s)
If there is more than one parent, the use of the singular incorporates the plural.
1.	I affirm that the minor child named above is my child and that I have legal custody of that child.
2.	I give my full authorization and consent for my child to live with and travel with the temporary guardian, and for the temporary guardian to establish a place of residence for my child.
3.	I give the temporary guardian permission to act in my place and make decisions pertaining to my child’s educational, recreational, and religious activities.
4.	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.
5.	This authorization shall cover the period from ______________, to _______________.
6.	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: ____________________________________________________________.
I declare under penalty of perjury under the laws of the state of __________________ that the foregoing is true and correct.

Parent 1’s signature: _____________________________________________
Date: ____________________

Parent 2’s signature: _____________________________________________
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. I agree to make necessary decisions and to provide consent for the minor as set forth in the above Authorization and Consent by Parent(s). I also agree to the terms of the costs of the minor's upkeep, living expenses, and medical and dental expenses as set forth in the above Authorization and Consent by Parent(s).
I declare under penalty of perjury under the laws of the state of ______________________ that the foregoing is true and correct.

Temporary guardian’s signature: _________________________________
Date: ____________________

Certificate of Acknowledgment of Notary Public

State of _______________________________	)
	)	ss
County of _____________________________	)

On _____________________, before me, ______________________________, a notary public in and for said state personally appeared ___________________ ________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he or she executed the same in his or her authorized capacity and that by his or her signature on the instrument, the person, or the entity upon behalf of which the person acted, executed the instrument.
	WITNESS my hand and official seal.
	_____________________________________
	Notary Public for the State of ______________
	My commission expires __________________
[NOTARY SEAL]