Temporary Guardianship Agreement printable pdf download

Temporary Guardianship Agreement

, 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.)

, hereby grant temporary custody of the above children,

whom I have legal custody of, to

 From

 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: _______________________________

Temporary Guardianship Agreement