TEMPORARY GUARDIANSHIP OF MINOR AUTHORIZATION

Minor
Full Legal Name: _ _______________
Date of Birth: _______________________ Age: ___________ Gender: ___ _____

Parent(s)/Legal Guardian(s):

Parent #1:
Name: _
Address: _______________________
Home phone: ________________ Work phone: ____None__________________
Cell phone: __________________ Pager: _______None____________________
Email: __ ________________
Additional Contact Information: _______N/A____________________________________________
_________________________________________________________________________________

Parent #2:
Name: _ _____________________________________
Address: __________________________________
Home phone: ________________ Work phone: ___________
Cell phone: __________________ Pager: ____None_______________________
Email: ____ _________________
Additional Contact Information: ______N/A_____________________________________________
_________________________________________________________________________________

Temporary Guardian(s):

Temporary Guardian #1:
Name: ___ ______________________________________________________________
Address: ________________________________________
Home phone: __________________ Work phone: __None____________________
Cell phone: ____________________ Pager: _____None______________________
Email: ___ _____________________________
Additional Contact Information: __________N/A_________________________________________
_________________________________________________________________________________

Temporary Guardian #2:
Name: ____.__________________________________________________________
Address: __ ______________________________________________________
Home phone: ________________ Work phone: ____None__________________
Cell phone: __________________ Pager: ____None_______________________
Email: _____None________________________
Additional Contact Information: _________N/A__________________________________________
_________________________________________________________________________________
Minor’s Doctor’s Information
Doctor’s Name: ___ _________________________________________________________________
Doctor’s Address: _Pediatric Associates Boynton Beach__________________________________________
Doctor’s Office Phone: ___________________ Doctor’s Emergency Phone: _____
Medical Insurer/Health Plan: _ Policy #: __ _____________
Allergies to Medications: ___ ______________________________________________
Allergies (Other): _____ _____________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_________N/A______________________________________________________________________
Note any other significant medical information:
________N/A______________________________________________________________________
_________________________________________________________________________________

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
1. I hereby declare that I have legal custody of the above named child.
2. I hereby grant my full permission and consent for the temporary guardian to establish a place of residence for my child, and for my child to reside and travel with said temporary guardian.
3. I hereby grant the temporary guardian my full authorization to make all decisions related to my child’s educational, religious, and recreational activities and undertakings.
4. I hereby grant the temporary guardian my full authorization to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the temporary guardian to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
5. This authorization is effective commencing on the 30th day of January, 2010 and expiring on the 13th day of March, 2010.
6. For the duration that the temporary guardian cares for my child, the costs associated with my child’s maintenance, living expenses, medical, and dental expenses shall be allocated and paid as follows: Insurance.
7. In the event that more than one legal guardian exists, the use of the singular shall incorporate the plural. In the event that more than one temporary guardian is named, the use of the singular shall incorporate the plural.
Under penalty of perjury under the laws of the state of Florida, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

Parent 1’s signature: ________________________________ Date: ____________________

Parent 2’s signature: ________________________________ Date: ____________________

CONSENT OF TEMPORARY GUARDIAN
I hereby acknowledge the terms set forth above and agree to assume responsibility in accordance with those terms.
Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

Temporary Guardian 1’s signature: ________________________________ Date: ____________________

Temporary Guardian 2’s signature: ________________________________ Date: ____________________

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF __________________
COUNTY OF ________________

This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal].
|[Notary Seal, if any]: | |
| |_______________________________ |
| |(Signature of Notarial Officer) |
| | |
| |Notary Public for the State of ______________ |
| | |
| |My commission expires: __________________ |
| | |