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Temporary Guardianship Agreement
I, _____________________________________________, of ___________________________________________
(print your full name) (street )
________________________________________________________, as the custodial parent of:
(city, state, zip)
List the full names of each child
List each child’s birth date
Do hereby grant temporary guardianship of the above listed children to:
List the full names of the individual (s) to whom you are
granting temporary custody
List each persons relationship to the child(ren)
Contact information of temporary guardians listed above:
Address: _____________________________________________________________________________________
Phone numbers: ________________________________________________________________________________
Statement of Consent: (To be signed in the presence of a legalized notary public.)
I, _____________________________________, hereby grant temporary guardianship of the above children, whom
I have legal custody of to ________________________________________________________________________:
From ________________________________to ___________________________________
(mm/dd/yyyy) (mm/dd/yyyy)
For as long as necessary, beginning on __________________________________________
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 child/children, in the event of
an accidental injury or illness. This permission includes, but is not limited to, the administration of first aid, and the
use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified
medical personnel. I also grant permission for the guardian(s) named above to make educational decisions for my
Signature: ______________________________________________________________ Date: _________________
Signature: ______________________________________________________________ Date: _________________
On this _______________day of _______________, _________, ________________________________________
(date) (month) (year) (name of parent)
personally appeared before me in ___________________________, _______________and, in my presence,
(city) (state)
has/have satisfactorily identified him/her/themselves as the signer(s) of this Temporary Guardianship Form.
Affix Notary
Name of Notary Official: ________________________________________________________ Seal Here
Signature: _____________________________________________________Commission Expires: ______________

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