Fill and Sign the Authorization Care Form

Temporary Guardianship Agreement with Detailed Authorization Regarding the Acquiring of Medical Care for Minor Children (Including Consent of Temporary Guardians) I, __________________________________ (name of custodial parent) of ____________________________________________________________________________ _____________________________________ (street address, city, county, state, zip code) , am the custodial parent of the following minor children: (Full name of each child, address, and date of birth) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________ As said custodial parent, I do hereby grant temporary custody of the above listed children to: (List the Full Names of the Individual(s) to Whom You Are Granting Temporary Custody and List Each Person’s Relationship to the Children) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____ From ______________________ (date) to ____________________ (date). or _____ For as long as necessary, beginning on ____________________ (date). The current address of ____________________________________________________ ______________________________________________ [Name(s) of temporary custodians] is __________________________________________________________________________ ____________________________________________________________________________ (street address, city, county, state, zip code) . CONSENT AS TO MEDICAL CARE In addition, in the event of an emergency or non-emergency situation requiring medical treatment, I hereby grant permission for any and all medical and/or dental attention to be administered to my said children, in the event of an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. I request that I be contacted as soon as possible in the case such medical care is necessary or appears to be necessary. Witness my signature this ________ day of _________________, 20_______. _________________________________________ _________________________________________ Printed name and signature of Custodial Parent STATE OF ____________________ COUNTY OF ____________________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of ___________________, 20______, within my jurisdiction, the within named ______________________________________ (Name of Custodial Parent), who acknowledged that he/she executed the above and foregoing instrument. ____________________________ NOTARY PUBLIC My Commission expires:_____________________ Consent of Temporary Guardian We hereby acknowledge that the terms set forth above are true and correct and agree to assume responsibility in accordance with those terms. Under penalty of perjury under the laws of the state of _________________, We attest to the truthfulness, accuracy, and validity of the forgoing statement. ___________________________________________ Printed name & signature of Temporary Guardian ___________________________________________ Printed name & signature of Temporary Guardian STATE OF ____________________ COUNTY OF ___________________ Personally appeared before me, the undersigned authority in and for the said county and state, on this ______ day of _________________, 20______, within my jurisdiction, the within named ______________________________________________________________________ (Names of Temporary Guardians) , who acknowledged that they executed the above and fore- going instrument. ____________________________ NOTARY PUBLIC My Commission expires: _____________________ (Acknowledgements may vary by State)