Florida Temporary Guardianship Form: Parent Agreement, Minor Health Care Surrogate and Chapter 751 Custody

Temporary Guardianship Agreement (Florida)

Parental Delegation of Care, with Designation of Health Care Surrogate for Minor

This agreement is made on [Date] in [County] County, Florida. It lets the parent(s) named below delegate 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 chapter 744 of the Florida Statutes. Section 5 is a designation of health care surrogate for a minor under section 765.2035, Florida Statutes.

1. Parties

Parent / Natural Guardian 1: [Full Legal Name]
Address: [Street, City, Florida ZIP] · Phone: [Phone] · Email: [Email]

Parent / Natural Guardian 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 (“Temporary Guardian”): [Full Legal Name]
Relationship to child: [Grandparent / aunt / uncle / adult sibling / stepparent / family friend]
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 deployment / medical treatment / 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
☐ Transport the child and arrange child care
☐ Consent to extracurricular activities, sports and camps
☐ Travel with the child within Florida ☐ 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, school enrollment or residence outside Florida without the parents’ written consent; or [other limits].

5. Designation of Health Care Surrogate for Minor (Fla. Stat. § 765.2035)

I/We, [Name(s)], the ☐ natural guardian(s) ☐ legal custodian(s) ☐ legal guardian(s) of the minor(s) named in Section 2, designate the caregiver named in Section 1 to act as my/our surrogate for health care decisions for the minor(s) in the event that I/we am/are not able or reasonably available to provide consent for medical treatment and surgical and diagnostic procedures.

Alternate health care surrogate, if the surrogate is not willing, able or reasonably available: [Name, Address, Phone].

I/We authorize physicians, hospitals and other providers of medical services to follow the instructions of the surrogate or alternate surrogate with regard to medical treatment and surgical and diagnostic procedures for the minor(s), provided the care is on the advice of a licensed physician. This designation ☐ includes ☐ does not include consent to medically necessary surgical and general anesthesia services. Mental health treatment decisions: ☐ included (the default if nothing is checked) ☐ excluded ☐ assigned to a separate surrogate: [Name, Phone]. This designation ends on the end date in Section 3 unless revoked earlier.

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

[This section must be signed by the parent(s) in the presence of two adult witnesses. The surrogate may not act as a witness. Give the surrogate an exact copy.]

6. 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].

7. 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].

8. 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. When the agreement ends, the caregiver will return all school, medical and identity documents.

9. Longer Arrangements: Consent to Chapter 751 Custody (Optional)

[Use only if the child will live with an extended family member for an extended period and the caregiver needs a court order.] We consent to [Caregiver], who is the child’s [relationship], petitioning the circuit court for ☐ temporary custody ☐ concurrent custody of the child under chapter 751, Florida Statutes. [This consent must be signed and notarized.]

10. Signatures

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

Witnesses to the designation of health care surrogate in Section 5 (two adults; the surrogate may not be a witness):

Witness 1: _________________________ Printed name and address: [ ]
Witness 2: _________________________ Printed name and address: [ ]

Notary acknowledgment (required for the Section 9 consent; recommended for the whole agreement)

State of Florida, County of [County]
The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this [day] day of [month], [year], by [Name(s) of person(s) acknowledging], who ☐ is/are personally known to me or ☐ produced [type of identification] as identification.

_________________________
Notary Public, State of Florida · Commission No. [ ] · My commission expires: [ ]

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 if the school requires a court order to enroll the child, use chapter 751.

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

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

• Divorced or separated parents. If a parenting plan or court order governs custody, check it first: this agreement cannot give the caregiver more authority than the signing parent has.