State of
County of
The Parent: , residing at .
The Child: , born on , residing at .
The Temporary Guardian: , residing at .
The Parent does hereby grant temporary guardianship of the Child named above to the Temporary Guardian from to .
The Temporary Guardian is authorized to:
It is acknowledged that the Child will reside with the Temporary Guardian and may travel locally with the Temporary Guardian.
The Temporary Guardian should note the following: .
The following information is essential in the case of medical treatment or hospitalization:
Medical insurer: .
Policy number: .
It is hereby declared that the Parent has the legal authority to appoint a Temporary Guardian for the Child, and the following statements are accurate to the best of the undersigned's knowledge that there are no existing court orders preventing the exercising or conferring the aforementioned rights and authority on the designated Temporary Guardian.
The undersigned freely and knowingly confers the aforementioned rights and responsibilities on the Child and is not under any pressure, threats, or payment from any person or agency.
If the undersigned wishes to amend or revoke this Form, they will provide a copy of the amended Form or revocation to all parties who received the original Form.
Name:
Signature: _______________________________
The Temporary Guardian's acknowledgment. I declare that I am at least 18 years of age. I understand that I may, without obtaining further consent from the Child's Parent/Legal Guardian, exercise concurrent power relative to the Child as authorized herein. However, I may not knowingly make a decision that conflicts with the decisions of the Child's Parent/Legal Guardian.
Under penalty of perjury, I affirm that the above statements are true and correct to the best of my knowledge.
Name:
Signature: _______________________________
Notary Acknowledgment
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
___________________________________
Place for signature
______________________________________
Notary public's name and seal
