Authorization Form For Temporary Guardianship Of Minor - Northern Virginia (Page 2 of 3) in pdf

Emergency Contact in Northern Virginia:

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

Home Phone: _______________________________

Work Phone: ___________________________

Cell Phone: ____________________________ Email Address: ________________________________

Additional Contact Information: ___________________________________________________________

The following is to be completed by the student’s parent(s) or legal guardian(s):

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 guardians 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 well being and extracurricular/recreational activities while enrolled at this school..

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 minor 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 beginning on _________________________ and ending on

month/day/year

_________________________.

month/day/year

6. 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 law, I attest to the truthfulness, accuracy, and validity of the forgoing

statement.

Parent 1’s Signature: __________________________________ Date: ______________________

Parent 2’s Signature: __________________________________ Date: ______________________

Authorization Form For Temporary Guardianship Of Minor - Northern Virginia Page 2