Fill and Sign the Guardianship Authorization Form

Temporary Guardianship Agreement with Detailed Authorization Regarding the Acquiring of Medical Care for Minor Children 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 fore going instrument. ____________________________ NOTARY PUBLIC My Commission expires: ________________________ (Acknowledgement may vary by State)