Guardianship Authorization Form - Woodland Christian School

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E
C
 
LEMENTARY  
AMPUS
 
!
1616  West  Street  
 Woodland  CA  95695  
G
UARDIANSHIP  
!
 
Phone  530.666.6615  
 Fax  530.666.3470  
 
M
&
H
S
C
 
IDDLE  
 
IGH  
CHOOL  
AMPUS
A
UTHORIZATION  
WOODLAND
CHRISTIAN
 
!
1787  Matmor  Road  
 Woodland  CA  95776  
!
 
 Phone  530.406.8800  
 Fax  530.406.0900  
F
ORM
 
   
 
1974
EST.
Please   f ill   i n   a ll   b lanks   ( including   p hone   n umbers   a nd   e mail   a ddresses)   b elow,   a nd   h ave   L EGALLY  NOTARIZED:  
We,   _ _________________________________________________   &   _ _________________________________________________,    
 
 
Print   F ather’s   F ull   L egal   N ame          
 
 
 
Print   M other’s   F ull   L egal   N ame  
parents   o f   _ ____________________________________________,   _ ___________________   g ive   L imited   P ower   o f   A ttorney   f or  
 
 
Print   M inor’s   F ull   L egal   N ame    
           
 
 
Birth   D ate  
Legal   G uardianship   o f   t his   c hild   t o   _ ___________________________________   &   _ _______________________________________.    
 
 
 
 
 
 
Legal   G uardian(s)’s   F ull   L egal   N ame  
 
Legal   G uardian(s)’s   F ull   L egal   N ame(s)
Parent’s   F oreign   A ddress  
City:  
Province   T erritory:  
Postal   C ode:  
Country:  
Fathers   P hone:  
Mothers   P hone:  
Fathers   E mail:  
Mothers   E mail:  
We,   t he   p arents,   h ave   c onsulted   w ith   t his   p erson(s)   a nd   t hey   h ave   a greed   t o   s erve   a s   L egal   G uardian.   I f  at  any  time  this  person(s)  is  no  longer  able  
or  willing  to  be  the  Legal  Guardian,  we  agree  to  find  new  a  Legal  Guardian  and  complete  a  new  Guardianship  Authorization  Form,  have  it  
notarized  and  submitted  to  Woodland  Christian  School  immediately.  
We   u nderstand   t hat:   i t  is  a  requirement  that  all  students  at  Woodland  Christian  School  must  live  with  an  adult  at  all  times.     I f   a t   a ny   t ime   t he  
legal   g uardian,   d esignated   a bove,   i s   o ut   o f   t he   i mmediate   a rea   m ore   t han   2 4   h ours,   t he   s chool   o ffice   m ust   b e   n otified   i mmediately   w ith   t he   n ame  
and   n umbers   o f   a   s ubstitute   c are   g iver   w ho   h as   a lso   b een   g iven   p ower   o f   a ttorney   b y   t he   p arents.   I   u nderstand   t hat   I   m ust   n otify   t he   s chool   o ffice  
immediately   i f   t here   i s   a ny   c hange   i n   A NY   o f   t his   i nformation.      
FAILURE  TO  COMPLY  WITH  ANY  OF  THE  ABOVE  MENTIONED  CONDITIONS  MAY  RESULT  IN  STUDENT’S  EXPULSION  AND  TERMINATION  OF  I-­‐20.    
  U .S.  Citizen      
  P ermanent  Resident  (green  card)  
Guardian  is:    
Male   G uardian:  
Female   G uardian:  
California   A ddress:  
California   A ddress:  
City:      
 
 
 
State  
          Z ip  
City:      
 
 
 
State  
          Z ip  
Home   P hone:  
Home   P hone:  
Cell   P hone:  
Cell   P hone:  
Work   P hone:  
Work   P hone:  
Email:  
Email:  
Host  Family  –  if  student  lives  away  from  Guardian,  please  complete:  
Home   S tay   M ale   G uardian:  
Home   S tay   F emale   G uardian:  
California   A ddress:  
California   A ddress:  
City:      
 
 
 
State  
          Z ip  
City:      
 
 
 
State  
          Z ip  
Home   P hone:  
Home   P hone:  
Cell   P hone:  
Cell   P hone:  
Work   P hone:  
Work   P hone:  
Email:  
Email:  
 
 
 
This  document  must  be  signed  by  PARENTS,  in  the  presence  of  a  LEGAL  NOTARY:  
 
Birth   P arent   S ignature:   _ __________________________________   D ate   _ ________________  
 
 
 
 
Notary   S ignature________________________________________   D ate   _ ________________  
Notary   S tamp  
Rev  12/2014  
1  

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