Temporary Guardianship Form printable pdf download

Temporary Guardianship Form

917 Sherwood Drive, First Floor, Lake Bluff, IL 60044-2203

2592 Grand Avenue, Lindenhurst, IL 60046-5915

870 West End Court, Suite 100, Vernon Hills, IL 60061-1377

847-295-1220

Fax 847-295-1255

Temporary Guardianship Form

We, __________________________ and ____________________, the parents of

(father)

(mother)

____________________________________________

(name of minor child)

Have temporarily given the guardianship of said child to:

_____________________________________________

(name of guardian or guardians)

The named guardians have full authority to sign and approve any emergency medical care

that the above mentioned child may require during our absence.

Our address and phone number, should notification be necessary because of serious illness,

is as follows:

___________________________________________________________

Telephone:__________________________________________

This release is effective from ___________________ to ______________

(date)

Important medical information for child:

Allergies:______________________________________________

Known medical illnesses: _________________________________

Medications currently being taken:__________________________

Date of last tetanus shot:__________________________________

Name/phone number of family

physician:_____________________________________________

Signature of Father____________________________________ Date_________

Signature of Mother___________________________________ Date_________

(emergency notification 02/21/13)

Temporary Guardianship Form