California Temporary Guardianship Form: Parent Authorization, Caregiver's Affidavit and Guardian Nomination

Temporary Guardianship Agreement (California)

Parent’s Authorization for the Care of a Minor, with Medical Consent (Family Code § 6910) and Nomination of Guardian (Probate Code § 1502)

This agreement is made on [Date] in [County] County, California. It lets the parent(s) named below entrust the day-to-day care of their child to a trusted adult while the parent(s) are temporarily unavailable. It is not a court order and does not appoint a guardian under the Probate Code. Section 5 authorizes the caregiver to consent to medical and dental care under section 6910 of the Family Code. Section 10 is an optional nomination of guardian under sections 1500 to 1502 of the Probate Code.

1. Parties

Parent 1: [Full Legal Name]
Address: [Street, City, California ZIP] · Phone: [Phone] · Email: [Email]

Parent 2: [Full Legal Name, or “Not applicable” with the reason, for example sole legal custody under court order dated [Date]]
Address: [Address] · Phone: [Phone]

Caregiver: [Full Legal Name]
Relationship to child: [Grandparent / aunt / uncle / adult sibling / stepparent / cousin / family friend]
☐ The caregiver is a relative of the child (related by blood, adoption or marriage within the fifth degree of kinship, including stepparents and stepsiblings)
☐ The caregiver is not a relative of the child
Address: [Street, City, State ZIP] · Phone: [Phone] · Date of birth: [Date]

Alternate caregiver (optional): [Full Legal Name, Relationship, Phone]

2. Child or Children

Full legal name	Date of birth	School and grade	Allergies or medical conditions
[Name]	[Date]	[School, grade]	[List, or “None”]
[Name]	[Date]	[School, grade]	[List, or “None”]

3. Period of Care

This agreement begins on [Start Date] and ends on [End Date], or earlier when a parent returns and resumes care or revokes it in writing. The reason for the arrangement is: [work travel / military service / medical treatment / immigration proceedings / other].

4. Authority Delegated to the Caregiver

During the period of care, the caregiver may (check all that apply):

☐ Provide daily care, supervision, food and shelter
☐ Deal with the child’s school: attendance, pick-up and drop-off, parent-teacher conferences, field trip and activity permission slips
☐ Enroll the child in a school where the caregiver lives, using a Caregiver’s Authorization Affidavit (Section 6)
☐ Transport the child and arrange child care
☐ Consent to extracurricular activities, sports and camps
☐ Travel with the child within California ☐ within the United States (a separate travel consent letter is attached for air travel)
☐ Other: [Describe]

The caregiver may not: consent to the child’s marriage, adoption or enlistment; change the child’s legal name or move the child’s residence outside California without the parents’ written consent; or [other limits].

5. Authorization to Consent to Medical and Dental Care (Family Code § 6910)

I/We, [Name(s)], the parent(s) of the minor(s) named in Section 2, authorize [Caregiver], an adult into whose care the minor(s) have been entrusted, to consent to ☐ medical care ☐ dental care for the minor(s) during the period of care in Section 3. ☐ The alternate caregiver has the same authority while the minor(s) are in the alternate caregiver’s care.

Except in an emergency, the caregiver will contact us before consenting to: [for example non-emergency surgery, new prescription medication, mental health treatment].

Health insurance: [Insurer, member ID, group number] · Pediatrician: [Name, Phone] · Dentist: [Name, Phone] · Current medications: [List]

6. School Enrollment and the Caregiver’s Authorization Affidavit

If the child will attend school in the district where the caregiver lives, the caregiver may complete and sign a Caregiver’s Authorization Affidavit in the form set out in section 6552 of the Family Code. We have been advised that the caregiver intends to authorize medical care for the child, and we do not object.

[The affidavit is a separate form signed by the caregiver alone, under penalty of perjury, and it needs no notary. A caregiver who completes items 1 to 4 may enroll the child and consent to school-related medical care; a relative who also completes items 5 to 8 may authorize medical and dental care. Its warnings must appear in at least 10-point bold type inside a box (Family Code § 6550(g)), so use a copy that reproduces the statutory form.]

7. Costs

The parent(s) will ☐ pay directly ☐ reimburse the caregiver within [Number] days for the child’s reasonable expenses, including [food, school costs, medical co-pays]. Estimated weekly support: $[Amount].

8. Communication and Emergencies

The caregiver will update the parent(s) [daily / weekly / as needed] by [phone / text / email] and immediately in any emergency. If the parent(s) cannot be reached, contact: [Name, Relationship, Phone].

9. Revocation and End of Agreement

A parent may revoke this agreement at any time by written notice to the caregiver, effective on delivery. The caregiver will return the child to the parent(s) on request. If the caregiver gave a Caregiver’s Authorization Affidavit to a school, health care provider or health plan, the caregiver will notify each of them when the child stops living with the caregiver (Family Code § 6550(f)). When the agreement ends, the caregiver will return all school, medical and identity documents.

10. Nomination of Guardian (Optional; Probate Code §§ 1500–1502)

If a court ever needs to appoint a guardian of the person of our child, we nominate [Caregiver] as guardian, and [Name] as alternate. This nomination takes effect ☐ now ☐ only if [we become absent / legally incapacitated / die / are unavailable because of ___]. Unless we revoke it in writing, it remains effective notwithstanding our subsequent absence, legal incapacity or death.

[A parent may nominate a guardian if the other parent nominates or consents in writing to the same guardian, or if, when the petition is filed, the other parent is dead or lacks legal capacity to consent, or that parent’s consent would not be required for an adoption of the child (Probate Code § 1500). The court gives the nomination due weight when it decides custody (Family Code § 3043).]

11. Signatures

Parent 1: _________________________ Date: __________
Parent 2: _________________________ Date: __________
Caregiver (accepting): _________________________ Date: __________
Alternate caregiver (accepting): _________________________ Date: __________

Notary acknowledgment (recommended; California form under Civil Code § 1189)

[Boxed notice:] A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California, County of [County]

On [date] before me, [name and title of the officer], personally appeared [name(s) of signer(s)], who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature: _________________________ (Seal)

Before You Sign (Delete This Section)

• Keep it short. A private agreement works best for absences of weeks or a few months. For a longer stay, or when a parent expects to be unavailable for a long time, ask the court: a guardianship petition, or a joint guardianship with the parent under Probate Code § 2105(g).

• Give copies. One to the caregiver, one to the school, one to the pediatrician. Keep the original.

• Caregivers who are not relatives. If the child will live with a caregiver who is not a relative, the law may require that caregiver to obtain resource family approval; the county department of social services can say whether it applies.

• Travel. For flights, especially international ones, add a separate child travel consent letter signed by both parents.

• Custody orders. If a custody order or parenting plan governs the child, check it first: this agreement cannot give the caregiver more authority than the signing parent has.