Authorization For Temporary Guardianship Of Minor (Page 2 of 3) in pdf

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: ____________________

Authorization For Temporary Guardianship Of Minor Page 2