Temporary Guardianship Authorization for Care of Minor
Child
Name: 	
Permanent address: 	
Phone: 	 Birthdate: 	
Child’s School or Day Care  
(Leave this section blank if your child is not in school or any type of child care program.)
School or day care program: 	
Teacher or day care provider: 	 Grade (if in school): 	
School or day care address: 	
	 Phone: 	
Child’s Doctor, Dentist, and Insurance
Doctor (or HMO): 	
Address:	
	 Phone: 	
Name of medical insurer/health plan: 	
Policy or medical records number: 	 
Phone:	
Dentist: 	
Address: 	
	 Phone: 	
Name of dental insurer/dental plan: 	
Policy number: 	 Phone: 	

Parents (or Legal Guardians)
Parent 1
Name: 	
Address: 	
	
Home phone: 	
Work phone: 	
Cell phone: 	 Email: 	
Parent 2
Name: 	
Address: 	
	
Home phone: 	
Work phone: 	
Cell phone: 	 Email: 	
Temporary Guardian
Name: 	
Address: 	
	
Home phone: 	
Work phone: 	
Cell phone: 	 Email: 	
Emergency Contact Information
In case of emergency, if a parent, guardian, or temporary guardian cannot be reached, contact:
Name: 	
Phone: 	Email: 	
Additional contact information: 	

Authorization and Consent of Parent(s) or Legal Guardian(s)
1.	I am the parent or legal guardian of, and have legal custody of, the minor child named above. 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.
2.	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 supervision by a physician, surgeon, dentist, or other medical practitioner licensed to practice in the United States.
3.	This authorization shall cover the period from 	 to 	 .
4.	While the temporary guardian cares for my child, the costs of my child’s upkeep, living expenses, and medical and dental expenses shall be paid as follows: 			
Parent 1’s signature 	
Date 	
Parent 2’s signature 	 
Date 	

Consent of Temporary Guardian
I solemnly affirm that I will assume full responsibility for the minor who will live with me during the period designated above.
Temporary guardian’s signature: 	
Date: 	

[OPTIONAL: ATTACH NOTARY CERTIFICATE]