Temporary Guardianship Form

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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)
(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)

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