Guardianship Power of Attorney Form Template

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Date: [Date]

Effective Date: [Effective Date]

Expiration Date (if any): [Expiration Date]

1. Parent/Legal Guardian Information

1.1 Parent/Guardian #1 Full Name: [Name]

1.2 Address: [Address]

1.3 Phone/Email: [Contact]

1.4 Relationship to Child: ☐ Mother ☐ Father ☐ Legal guardian ☐ Other: [Relationship]

Parent/Guardian #2 (if applicable):

1.5 Full Name: [Name]

1.6 Address: [Address]

1.7 Phone/Email: [Contact]

1.8 Relationship to Child: ☐ Mother ☐ Father ☐ Legal guardian ☐ Other: [Relationship]

2. Child Information

2.1 Child Full Legal Name: [Name]

2.2 Date of Birth: [MM/DD/YYYY]

2.3 Current Address: [Address]

2.4 School/Provider (Optional): [School/Provider]

3. Agent (Temporary Guardian/Caregiver) Information

3.1 Agent Full Name: [Name]

3.2 Address: [Address]

3.3 Phone/Email: [Contact]

3.4 Relationship to Child: [Relationship]

4. Grant of Authority

4.1 I/We appoint the Agent named above to act as my/our attorney-in-fact for the minor child identified in Section 2 for the limited purposes stated in this form.

5. Powers Granted (Select All That Apply)

5.1 The Agent is authorized to (check all that apply):

☐ Provide day-to-day care and supervision

☐ Enroll the child in school and sign school forms

☐ Attend parent-teacher meetings and access school records

☐ Arrange childcare and extracurricular activities

☐ Consent to routine medical, dental, and vision care

☐ Consent to emergency medical treatment and hospital admission

☐ Obtain and share medical records for treatment

☐ Travel with the child (domestic/international) as described in Section 6

☐ Other limited authority: [Describe]

5.2 The Agent is not authorized to:

☐ Consent to marriage ☐ Consent to adoption ☐ Change legal custody (unless allowed by law) ☐ Other: [Limits]

6. Travel Authorization (Optional)

6.1 The child may travel with the Agent to: [Destinations].

6.2 Travel dates (if limited): From [Start Date] to [End Date].

6.3 Additional travel notes (optional): [Airline info, passport, contacts].

7. Medical Information (Optional)

7.1 Primary Doctor/Clinic: [Name/contact]

7.2 Insurance Provider/Policy #: [Details]

7.3 Allergies/Medications: [List]

7.4 Emergency Contacts: [Names/phones]

8. Term and Revocation

8.1 This authorization begins on the Effective Date and ends on the Expiration Date above (or earlier if revoked).

8.2 I/We may revoke this authorization in writing at any time, subject to applicable law.

8.3 If this form is used for a specific event/travel period, it ends automatically after: [Event/end date].

9. Reliance by Third Parties

9.1 Third parties may rely on this document unless they have actual knowledge it has been revoked or expired, to the extent permitted by law.

10. Governing Law (Optional)

10.1 This form is governed by the laws of [State/Country], to the extent applicable.