To travel with the child(ren) without limitations unless stated below:
within a _____-mile radius of ;
within the city county/parish state lines of
only; or
other (e.g., to/from the following places only):
.
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) (Pub. L. 104-191),
45 CFR §§ 160-162, I/we are the Personal Representative of the minor child(ren) named above, and I/we
appoint and designate the above named short-term guardian(s)/health care agents as their Personal
Representative(s) for all purposes as provided in HIPPA, with the following limits, special conditions, or
instructions: None or
. I/we further appoint the short-term guardian(s) named herein as
Authorized Recipients under HIPPA and the California Confidentiality of Medical Information Act (“CMIA”),
entitled to request, receive, and review any information concerning the child(ren)’s physical or mental
health, including all HIPPA and CMIA protected information and medical and hospital records from
covered healthcare providers and to execute any releases or consents and pay any fees in connection
therewith.
It is my/our intention that the short-terms guardian(s) serve without bond or compensation other than
reimbursement of expenses incurred on the child(ren)’s behalf. I/we shall remain personally liable for the
payment of all healthcare and education related expenses for the child(ren) to the same extent as if I/we
had personally contracted for such services. No third party shall have any liability to me/us for reasonably
relying on this document in good faith. If I/we have named two or more short-term guardians above,
either may act in the absence of the other(s).
I/We have executed this appointment and power of attorney in front of a notary public. Those of the
child(ren) named above who are 14 years of age or older may optionally also sign below to indicate their
seconding of the nomination of court-appointed guardians.
CUSTODIAL PARENT(S)/GUARDIAN(S):
Sign:
Sign:
Print Name:
Print Name:
Date Signed:
Date Signed:
(OPTIONAL) NOMINATION OF PERSONS ABOVE AS GUARDIANS BY MINORS 14+:
Sign:
Sign:
Print Name:
Print Name:
Date Signed:
Date Signed:
CONSENT OF SHORT-TERM GUARDIANS:
I/We have read the foregoing and with full knowledge and awareness of the gravity of the duties
delegated and assumed hereunder, I/we agree to assume full responsibility and to make decisions
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