Authorization of Temporary Guardianship

PLEASE CLEARLY PRINT ALL INFORMATION

Month (MMM) Day (DD) Year (YYYY)

Parent/Legal Guardian Information

Parent/Legal Guardian #1

Parent/Legal Guardian #2

Temporary Guardian Information

Temporary Guardian #1

Authorization of Temporary Guardianship Cont’d

Temporary Guardian #2

Emergency Contact Information (If different from previous)

Authorization of 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. I also grant the temporary guardian my full authorization to sign, on my behalf, any and all medical consent or parental permission forms required for school, day-care, camp, or field-trip enrollment.

5.     This authorization is effective commencing on the ______ day of _________________________, 20_______ and expiring on the ________ day of __________________________, 20_____.

6.     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 the penalty of perjury under the laws of the state of New York, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

________________________________________________________________________                                    _________________________

Parent/Legal Guardian #1 Signature Date

________________________________________________________________________                                    _________________________

Parent/Legal Guardian #2 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 the penalty of perjury under the laws of the state of New York, I attest to the truthfulness, accuracy, and validity of the forgoing statement.

________________________________________________________________________                                    _________________________

Temporary Guardian #1 Signature Date

________________________________________________________________________                                    _________________________

Temporary Guardian #2 Signature Date

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