Appointment Of Short-Term Guardian For Minor Child(Ren) And Durable Healthcare Power Of Attorney Page 4

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necessary for the well being of the minor child(ren) named above who will be living
with me/us during the short-term guardianship period in accordance with the best interests of the child
and agree to surrender the child(ren) to the parent(s)/guardian(s) upon request at any time or as specified
herein.
Sign:
Sign:
Print Name:
Print Name:
Date Signed:
Date Signed:
State of California
)
County of
)
On
before me,
, Notary Public, personally
appeared
, who proved to me on the basis of satisfactory
evidence to be the person whose name is subscribed to the within instrument and acknowledged
to me that she executed the same in her authorized capacity, and that by her signature on the
instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
I certify under PENALTY of PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
(Seal)
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