SAMPLE CHILD GUARDIAN CONSENT FORM
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About This Form
Individuals or organizations whom you may wish to provide temporary custody of your child/children in your absence may require this form. This consent form grants authorization to provide for your child's needs(such as the ability to transport your child to and from school and activities, agree to medical care and treatment when needed and sign forms on your behalf relating to the care and support of your child).
Include addresses and telephone numbers of where you or your spouse can be reached in an emergency.
CHILD GUARDIAN CONSENT FORM
I [YOUR NAME] of [YOUR ADDRESS] , [YOUR CSZ] , do appoint [GUARDIAN NAME] of [GUARDIAN ADDRESS] , [GUARDIAN CSZ] as the legal guardian for my child:
Child's Name
[CHILD'S NAME]
Birthdate
[DATE]
The guardian shall have the right to:
1. Determine and authorize necessary medical attention.
2. Provide necessary clothing, food, and shelter
3. [SPECIFIC DUTIES]
Executed this ________ day of ____________________, _____________________________________
[YOUR NAME]State of [NOTARY STATE] ) ) ss. County of [COUNTY/PARISH NOTARY] ) On this ______ day of ____________________, _____, before me, the undersigned, a Notary Public in and for the State and County named above, personally appeared [YOUR NAME] , known to me or satisfactorily proven to be the person who executed the foregoing instrument, and who have acknowledged the execution of the same. Subscribed and sworn to before me this ________ day of _________________________, _____. My Commission Expires: _____________________________ ______________________ NOTARY PUBLIC (SEAL)
Copyright © 1997 OverDrive Systems, Inc.
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