Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of Attorney

APPOINTMENT OF SHORT-TERM GUARDIAN FOR MINOR CHILD(REN) AND DURABLE HEALTHCARE POWER OF ATTORNEY

I/We, and , constituting the sole or all of the custodial parent(s) or court-appointed guardian(s) of the child(ren) named below, and residing at hereby appoint

(1) , residing at , with telephone number(s) and having the following relationship(s) to me us the minor(s): ;

and (optional) (2) , residing at , with telephone number(s) and having the following relationship(s) to me us the minor(s): ,

to serve as the short-term guardian(s) over, and health care agents for, the following minor child(ren) (If more space is needed here or elsewhere, attach additional sheets):

Full name: DOB:

Full name: DOB:

Full name: DOB:

and will become effective (check one):

immediately;

on ;

upon the deaths, incapacity, or absence of all parents/guardians listed above; or

the occurrence of the following triggering event(s):

and will terminate upon the earlier to occur of (a) the revocation in writing of any parent/guardian, (b) as required by applicable law, or (c) (check one):

60 days;

on the day of ; or

the occurrence of the following triggering event(s):

Additionally it is my/our intention that, if a court-appointed guardian is required for the child(ren), this document shall additionally serve as a nomination of the above listed short-term guardians under Probate Code Section 1502 et seq., who I/we believe will act in the child(ren)’s best interest.

It is my/our express intention that the child(ren) not be taken into government child protective custody or foster care, unless all other short-term guardian(s) are exhausted and even then I prefer that other relatives assume custody of the child(ren) unless this box is checked: .

To the maximum extent permissible under applicable law, the short-term guardian(s) will have the same authority as I/we would have with respect to the custody and care of the minor child(ren), except as I/we have specified below:

To make all emergency and non-emergency healthcare decisions and execute all related documents including insurance and waiver claims and forms.

To make all decisions, execute all documents, and grant permission regarding the child(ren)’s education, including but not limited to school enrollment, school and extracurricular activities, school trips, and school conferences.

To generally do and perform all matters and to execute all documents with respect to the custody and care of the child(ren) named herein.

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”), 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:

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”).

It is my/our intention that the short-term guardian(s) serve without bond or compensation other than reimbursement of expenses incurred on the child(ren)’s behalf.

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.

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 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.

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)

REVOCATION OF SHORT-TERM GUARDIANSHIP

I/We, hereby revoke

the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of Attorney dated the ; or

any and all Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of Attorney forms

with regard to

all minor child(ren) listed therein, or

the following named minor child(ren) only:

previously executed by me/us, effective as of

immediately;

the ; or

the occurrence of the following event(s) or condition(s), which were not previously specified in the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of Attorney dated the

After signing, provide copies of this Revocation to the short-term guardian(s) whose power are being terminated and to any third parties known to be relying on the short-term guardian(s)’s powers immediately.

ADDITIONAL INFORMATION

Child: Nickname(s):

Date of birth and last Tetanus Booster for the above named child.

The following is a list of known allergies and allergies to medications of the above named child:

The above named child has the following known medical conditions or problems:

The above named child is currently prescribed the following prescriptions medications at the following frequencies and other instructions:

Family Physician: Phone Number:

Names of Parents/Guardians:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Person Responsible for charges:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Other Person to notify if parent/guardian is unavailable:

Phone: (H) ; (W) ; (Other)

Insurance Company: Policy or Group Number:

Signature of Financial Guarantor (required if different from parent/guardian):

Date: Print and complete one sheet per child

ADDITIONAL INFORMATION

Child: Nickname(s):

Date of birth and last Tetanus Booster for the above named child.

The following is a list of known allergies and allergies to medications of the above named child:

The above named child has the following known medical conditions or problems:

The above named child is currently prescribed the following prescriptions medications at the following frequencies and other instructions:

Family Physician: Phone Number:

Names of Parents/Guardians:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Person Responsible for charges:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Other Person to notify if parent/guardian is unavailable:

Phone: (H) ; (W) ; (Other)

Insurance Company: Policy or Group Number:

Signature of Financial Guarantor (required if different from parent/guardian):

Date: Print and complete one sheet per child

ADDITIONAL INFORMATION

Child: Nickname(s):

Date of birth and last Tetanus Booster for the above named child.

The following is a list of known allergies and allergies to medications of the above named child:

The above named child has the following known medical conditions or problems:

The above named child is currently prescribed the following prescriptions medications at the following frequencies and other instructions:

Family Physician: Phone Number:

Names of Parents/Guardians:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Person Responsible for charges:

Address:

City/State/Zip:

Phone: (H) ; (W) ; (Other)

Other Person to notify if parent/guardian is unavailable:

Phone: (H) ; (W) ; (Other)

Insurance Company: Policy or Group Number:

Signature of Financial Guarantor (required if different from parent/guardian):

Date: Print and complete one sheet per child