Parental Consent To Award Temporary Legal Custody Form - Santa Rosa County, Florida

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IN THE CIRCUIT COURT IN AND FOR SANTA ROSA COUNTY, FLORIDA
IN THE INTEREST OF:
________________________________
Case Number:_________________________
D.O.B.:__________________________
Division:______________________________
PARENTAL CONSENT TO AWARD TEMPORARY LEGAL CUSTODY
The undersigned, being duly sworn, here by states:
1. My name is: _________________________________________________________.
2. My current address is _________________________________________________.
3. I am the ( ) Mother ( ) Father of the above named child.
4. I hereby give consent for____________________________to have temporary legal custody of my child.
5. I understand this consent may be filed with the Court record in_____________________County, Florida.
6. I understand that at any time after the Court enters an Order awarding temporary legal custody of my
child to ___________________________, I may request the Court terminate the Order and return my
legal custody to me.
7. I understand by giving this consent, the Court will authorize___________________________________
to take all necessary steps to care for my child, including but not limited to the following:
A. Authorize and consent to all reasonable and necessary medical and dental care, including non-
emergency surgery and psychiatric care.
B. Secure copies of the child’s records held by third parties that are necessary to the care of the child,
including but not limited to, medical dental and psychiatric records, birth certificates and educational
records.
C. Enroll the child in school and grant or withhold consent for the child to be tested or placed in special
school programs, including exceptional education.
D. Do all other things necessary for the care of the child.
______________________________________
__________________________________________
Parent’s Signature
Parent’s name typed or printed
STATE OF FLORIDA COUNTY OF SANTA ROSA
SWORN TO AND SUBSCRIBED before me this______ day of ___________________________, 20_______.
DONALD C. SPENCER
( ) Personally known
CLERK OF THE CIRCUIT COURT
( ) Produced Identification_____________
BY:_______________________________________________
Deputy Clerk
OR
__________________________________________________
Notary Public – State of Florida

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