Temporary Guardianship Agreement
I,
, of
(print your full name)
(list your street address)
, as the custodial parent of:
(city, state, zip, phone number)
List the Full Names of Each of Your Children
List Each Child’s Birth Date
do hereby grant temporary custody of the above listed children to:
List the Full Names of the Individual(s) to Whom
List Each Person’s Relationship
You are Granting Temporary Custody
to the Children
Mr./Ms./Mrs.
’s current address is
.
Statement of Consent: (To be signed in the presence of a legalized notary public.)
I,
, hereby grant temporary custody of the above children,
whom I have legal custody of, to
:
From
to
.
For as long as necessary, beginning on
.
In addition, in the event of an emergency or non-emergency situation requiring medical treatment, I
hereby grant permission for any and all medical and/or dental attention to be administered to my
child/children, in the event of an accidental injury or illness, until such time as I can be contacted. This
permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the
administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.
Signature:
Date:
Notarization:
On this
day of
,
,
(date)
(month)
(year)
(name of parent)
personally appeared before me in
County (in the state of
) and, in my
presence, signed this Temporary Guardianship form.
Name of Notary Official: ______________________________
Signature: _______________________________________
Commission Expires: _______________________________