Temporary Guardianship for Care of Minor

Use this legal form when you need when you give short-term care of your child to another adult. 

This form establishes a temporary “informal guardianship,” which is different from a formal, court-approved guardianship.

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See below the form for a full product description.

 

Authority of Temporary Guardian

Alternate Selection
Label Contract Text
one

I, , am the parent or legal guardian of, and have legal custody of, . I authorize to serve as temporary guardian of .

I authorize my child to live with and travel with the temporary guardian. I give the temporary guardian permission to care for my child in my place and make decisions pertaining to my child's care, including educational, recreational, and religious activities.

I give the temporary guardian permission to authorize medical and dental care for my child, including but not limited to medical examinations, X-rays, tests, anesthesia, surgical operations, hospital care, or other treatments that in the temporary guardian's sole opinion are needed or useful for my child. Such medical treatment shall be provided only upon the advice of and supervised by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.

two

We,   and  , are the parents or legal guardians of, and have legal custody of, . We authorize  to serve as temporary guardian of .

We authorize our child to live with and travel with the temporary guardian. We give the temporary guardian permission to care for our child in our place and make decisions pertaining to our child's care, including educational, recreational, and religious activities. 

We give the temporary guardian permission to authorize medical and dental care for our child, including but not limited to medical examinations, X-rays, tests, anesthesia, surgical operations, hospital care, or other treatments that in the temporary guardian's sole opinion are needed or useful for our child. Such medical treatment shall be provided only upon the advice of and supervised by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.

Duration of Temporary Guardianship

This authorization will be in effect from  to .

Multiple Selection
Label Contract Text
yes, I want to detail how expenses will be paid

Payment of Expenses

While the temporary guardian cares for my child, my child's living expenses and medical and dental expenses shall be paid as follows: 

Child's Information

Name: 
Permanent address: 
Phone: 
Birthdate: 

Multiple Selection
Label Contract Text
yes, include school or daycare information

Child's School or Daycare

School or daycare program: 
Grade (if in school): 
Teacher or daycare provider: 
Address: 
Phone: 

Other child care: 

Child's Doctor, Dentist, and Insurance

Doctor: 
Address: 
Phone: 

Health insurer or health plan: 
Policy or medical records number: 
Name of insured parent: 

Dentist: 
Address: 
Phone: 

Dental insurer: 
Policy number: 

Parent Contact Information

Alternate Selection
Label Contract Text
one parent or guardian

Name: 
Address: 
Phone:  
Email: 

two parents or guardians

Name: 
Address: 
Phone:   
Email: 

Name: 
Address: 
Phone:  
Email: 

Temporary Guardian Information

Name: 
Address: 
Phone: 
Email: 
Relationship to child: 

Emergency Contact Information

In case of emergency, if a parent, guardian, or temporary guardian cannot be reached, contact:

Name: 
Phone: 
Email: 

Additional contact information: 

Keep Together
Alternate Selection
Label Contract Text
one

Signature

Signature: _______________________________
Date: ______________________________

two

Signatures

Signature: _______________________________
Date: ______________________________

Signature: _______________________________
Date: ______________________________

Consent of Temporary Guardian

I solemnly affirm that I will assume full responsibility for the care of , who will live with me during the period designated above.

Signature: _________________________________
Date: ____________________________

Page Break

Certificate of Acknowledgment of Notary Public

State of _____________________________________________    )

                                                                                                                            )           ss

County of ___________________________________________     )

 

On _______________ before me, _________________________________________ (here insert name and title of the officer) personally appeared _______________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ___________ that the foregoing paragraph is true and correct.

                                                            WITNESS my hand and official seal.

                                                            _____________________________________

                                                            Notary Public for the State of ______________

                                                            My commission expires __________________

[NOTARY SEAL]

 

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