Parental Consent / Authorization for Guardianship of a Minor Template

Date: [Date]
Effective Date: [Effective Date]
Expiration Date: [Expiration Date]

1. Parent/Legal Guardian Information

Parent/Guardian #1:
1.1 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. Minor (Child) Information

2.1 Full Legal Name: [Child Name]
2.2 Date of Birth: [MM/DD/YYYY]
2.3 Current Address: [Address]
2.4 School/Program (Optional): [Name]

3. Proposed Guardian (Authorized Caregiver)

3.1 Full Name: [Guardian Name]
3.2 Address: [Address]
3.3 Phone/Email: [Contact]
3.4 Relationship to Child: [Relationship]

4. Scope of Guardianship Authorization

4.1 We authorize the Guardian to provide day-to-day care and supervision for the child during the term stated below.
4.2 Powers Granted (Select All That Apply):
☐ Enroll the child in school and sign school forms
☐ Access school records and attend meetings
☐ 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 as described in Section 5
☐ Other limited authority: [Describe]

4.3 Limits/Restrictions (Optional): [Any limits on travel, medical decisions, locations, or providers.]

5. Travel Authorization (Optional)

5.1 Destinations: [Countries/Cities/States].
5.2 Travel Dates: From [Start Date] to [End Date].
5.3 Travel Notes (Optional): [Flights, lodging, passport details].

6. Custody Statement (Optional)

6.1 Custody status: ☐ Joint custody ☐ Sole custody ☐ Other: [Explain].
6.2 Court order (if any): [Court, date, case number]. ☐ Attached.

7. Term and Revocation

7.1 This authorization begins on the Effective Date and ends on the Expiration Date above, unless revoked earlier in writing.
7.2 We may revoke this authorization at any time by providing written notice to the Guardian and any relevant school/medical provider.

8. Reliance by Third Parties

8.1 Third parties may rely on this authorization unless they have actual knowledge it has been revoked or expired, to the extent permitted by law.

Signatures

Parent/Guardian #1: [Full Name]
Date: [Date]
Signature: ___________________________

Parent/Guardian #2 (if applicable): [Full Name]
Date: [Date]
Signature: ___________________________

Authorized Guardian (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 (Optional)

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): ___________________