TEMPORARY GUARDIANSHIP FORM SAMPLE
Free Printable Blank Authorization Template
Temporary guardianship form are used by natural parents or legal guardians:
- who will be medically incapacitated
- parents who are leaving the country for a brief period of time
- in case consent to medical treatment is required
- in case educational decisions concerning the child or children is needed
- consent to residential custody of the minor child or children
- give authority to seek dental treatment for the child or children
These types of legal temporary guardianship forms can last for 30, 60 or up to 90 days or more.
CHILD GUARDIANSHIP CONSENT FORM
THE PARENT(s) / GUARDIAN(s)
Full Name: _________________________________ DOB: ___/___/___
Driver License #: ______________________________ State: ___________
Physical Address: _____________________________________________
Home Phone: ________________ Cell: ______________ Work: __________
Relationship to minor: _________________________________________
Full Name: _________________________________ DOB: ___/___/___
Driver License #: ______________________________ State: ____________
Physical Address: ______________________________________________
Home Phone: ________________ Cell: ______________ Work: ___________
Relationship to minor: __________________________________________
THE TEMPORARY GUARDIAN(s)
Full Name: _________________________________ DOB: ___/___/___
Driver License #: ______________________________ State: ____________
Physical Address: ______________________________________________
Home Phone: ________________ Cell: ______________ Work: ___________
Relationship to minor: ___________________________________________
Full Name: _________________________________ DOB: ___/___/___
Driver License #: ______________________________ State: ____________
Physical Address: ______________________________________________
Home Phone: ________________ Cell: ______________ Work: ___________
Relationship to minor: __________________________________________
THE CHILD/CHILDREN
Child Full Legal Name: _______________________
Gender:_______ Date of Birth: ___/___/___ Age: ____ SSN: ___-__-____
School Grade: _______________________
Child Full Legal Name: _______________________
Gender:_______ Date of Birth: ___/___/___ Age: ____ SSN: ___-__-____
School Grade: _______________________
EMERGENCY CONTACT
In case of emergency, if the guardian or parents cannot be reached, please contact:
Home phone: _____________ Cell: _____________
Work: _____________ Email: _____________
In case medical treatment or hospitalization becomes necessary:
Employer: ________________________________
Address: ___________________________________________
Medical Aid / Insurer: __________________________________
Policy Number: ____________________________
Authorization and Consent of Parent(s) or Legal Guardian(s)
Upon my disability, I designated the guardian(s) stated above to have the following authority:
a) live with and travel with the minor child or children;
b) residential custody of the minor child or children;
c) to approve medical treatment of any kind or type or to disapprove the same within the bounds of the law;
d) permission to act in my place and make decisions pertaining to the child's recreational, educational, and religious activities;
e) access to any and all of the child’s educational records;
d) permission to authorize medical and dental care for the child or children.
While the temporary guardian cares for the minor child, the costs of the child's upkeep, living expenses, and medical and dental expenses shall be paid as follows: ______________________________________________________.
I declare that I am the Parent/Legal Custodian and that I have legal authority to appoint a Temporary Guardian for the Minor Child or Children named above.
I declare under penalty of perjury under the laws of the state of _______________ that the foregoing is true and correct to the best of my knowledge.
This temporary authorization form is effective commencing on the _______ day of ___________ 20___ and expiring on the ______ day of ________________ 20___.
Father's signature: ________________________ Date: ___/___/___
Mother's signature: _______________________ Date: ___/___/___
WITNESS 1: ________________________
WITNESS 2: ________________________
Certificate of Acknowledgment of Notary Public
State of ___________________ )
) ss
County of ___________________ )
On ___________________, before me, ___________________, a notary public in and for said state, personally appeared ___________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within this temporary guardianship form 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.
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.
_______________________________
Notary Public for the State of ___________________
My commission expires ___/___/_____ [NOTARY SEAL]
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