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Guardianship Power of Attorney Form Template
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Guardianship Power of Attorney Form Template
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.
Signatures
Parent/Guardian #1: [Full Name]
Date: [Date]
Signature: ___________________________
Parent/Guardian #2 (if applicable): [Full Name]
Date: [Date]
Signature: ___________________________
Agent (Acknowledgment, Optional): [Full Name]
Date: [Date]
Signature: ___________________________
Witnesses (If Required)
Witness #1 Name: [Name]
Date: [Date]
Signature: ___________________________
Witness #2 Name: [Name]
Date: [Date]
Signature: ___________________________
Notary / Notarization (If Required)
State of [State]
County of [County]
On [Date], before me, [Notary Name], personally appeared [Parent/Guardian Name(s)], known to me (or satisfactorily proven) to be the person(s) whose name(s) are subscribed to this document, and acknowledged that they executed it for the purposes stated.
Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________
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Guardianship Power of Attorney Form Template
GUARDIANSHIP POWER OF ATTORNEY FORM TEMPLATE FAQ
What is a guardianship power of attorney for a child?
A Guardianship Power of Attorney (sometimes called a Minor Power of Attorney or Temporary Caregiver Authorization) is a document where a parent or legal guardian authorizes another adult (the “Agent”) to make certain decisions for a minor child. It is commonly used for temporary caregiving, travel, school matters, and medical decisions when a parent is unavailable.
Is a guardianship POA the same as legal guardianship?
No. A POA typically grants temporary authority and does not permanently change custody or guardianship rights. A court-ordered guardianship involves a legal process and may be required for longer-term arrangements or specific situations.
What decisions can the agent make?
It depends on what the parent authorizes. Common powers include: enrolling the child in school, attending school meetings, consenting to routine and emergency medical care, arranging childcare, and managing travel. This template allows you to select and limit powers.
How long does it last?
Many jurisdictions limit how long a minor POA can last (for example, 6–12 months), and some require specific wording. This template includes a term section you can adjust to match local rules.
Should it be notarized?
Often yes, and sometimes witnesses are required. Notarization can help with acceptance by schools and medical providers. This template includes optional witness and notary sections, to use if required.
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