New York Temporary Guardianship Form: Designation of Person in Parental Relation and Standby Guardian

Designation of Person in Parental Relation (New York)

Temporary Guardianship Form under Title 15-A of the New York General Obligations Law (§§ 5-1551 to 5-1555), with Optional Designation of Standby Guardian (Surrogate’s Court Procedure Act § 1726)

This designation lets the parent named below designate another adult as a person in parental relation to the child or children named below, for a period of up to twelve months. It is not a court order and does not appoint a guardian. Part B is an optional designation of standby guardian, which takes effect only in the circumstances it describes.

Part A. Designation of Person in Parental Relation

1. Parent

Name: [Full Legal Name]
Address: [Street, City, New York ZIP] · Telephone: [Phone]

Second parent (if signing): [Full Legal Name]
Address: [Address] · Telephone: [Phone]

2. Designee

Name: [Full Legal Name]
Relationship to child: [Grandparent / aunt / uncle / adult sibling / family friend / other]
Address: [Street, City, State ZIP] · Telephone: [Phone]

3. Child or Children

Full legal name	Date of birth
[Name]	[Date]
[Name]	[Date]

4. Period of the Designation

This designation commences on ☐ [Date] ☐ the following event: [for example, the day I leave for deployment or begin inpatient treatment].

It is valid for (check one):
☐ 30 days or less, until [Date]
☐ more than 30 days, until [Date, no later than twelve months after it commences]

unless I revoke it earlier. [A designation for more than thirty days must include every item in Sections 1 to 6 and must be notarized. If no period is stated, it lasts thirty days from signing, or twelve months from its commencement if it meets the requirements for longer designations (General Obligations Law § 5-1552).]

5. Authority of the Designee

The designee shall possess all the powers and duties of a person in parental relation pursuant to sections 2164 and 2504 of the Public Health Law and sections 2 and 3212 of the Education Law, except as limited below (General Obligations Law §§ 5-1553, 5-1555).

Consent is authorized for: ☐ medical, dental, health and hospital care ☐ immunizations ☐ school matters, including attendance, conferences, permission slips and activities ☐ other: [Describe]

Consent is not authorized for: [for example, non-emergency surgery or new psychiatric medication without first contacting the parent]

Other limitations: [for example, no travel outside New York State without the parent’s written consent]

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

6. Statements of the Parent

There is no prior order of any court in any jurisdiction currently in effect prohibiting me from making this designation.

☐ A court has ordered that both parents must agree on education or health decisions regarding the child. Both parents consent to this designation and sign below. [Without the consent of both parents, the designation is not valid in that case (General Obligations Law § 5-1551).]

7. Revocation, Effect and Parent’s Decisions

A parent may revoke this designation at any time by notifying, orally or in writing, the designee or any school, health care provider or health plan to which it has been presented, or by any other act showing a specific intent to revoke it. Signing a later designation also revokes it. Revocation by one parent is effective. A designee who is told of a revocation must promptly notify every school, health care provider and health plan to which the designation was presented (General Obligations Law § 5-1554).

This designation ends upon the death or incapacity of the parent who signed it. A decision of the parent overrides a contrary decision of the designee. The designation does not make the designee responsible for the child’s support and does not change the child’s school district of residence (General Obligations Law § 5-1555).

8. Signatures

Parent: ___________________________ Date: __________
Second parent (if signing): ___________________________ Date: __________

Consent of designee. I consent to this designation as a person in parental relation to the child or children named above.

Designee: ___________________________ Date: __________

Notary acknowledgment (required for a designation of more than thirty days)

State of New York, County of [County], ss.:

On the [day] day of [month] in the year [year] before me, the undersigned, personally appeared [name(s) of parent(s)], personally known to me or proved to me on the basis of satisfactory evidence to be the individual(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 capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

___________________________
Notary Public, State of New York

Part B. Designation of Standby Guardian (Optional; Surrogate’s Court Procedure Act § 1726)

I, [Name of parent], hereby designate [Name, home address and telephone number of standby guardian] as standby guardian of the person and property of my child(ren) [Name(s) of child(ren)]. [To limit the authority to the person, or to the property, of the child, cross out the word that does not apply.]

The appointment of [Name] as the standby guardian of the person and property of my child(ren) would be in the best interests of my child(ren) because: [Reasons].

The standby guardian’s authority shall take effect: (1) if my doctor concludes in writing that I am mentally incapacitated, and thus unable to care for my child(ren); (2) if my doctor concludes in writing that I am physically debilitated, and thus unable to care for my child(ren), and I consent in writing, before two witnesses, to the standby guardian’s authority taking effect; (3) if I become subject to an administrative separation such that care and supervision of the child will be interrupted or cannot be provided; or (4) upon my death.

In the event the person I designate above is unable or unwilling to act as guardian for my child(ren), I hereby designate [Name, home address and telephone number of alternate standby guardian] as standby guardian of my child(ren).

I also understand that my standby guardian’s authority will cease sixty days after commencing unless by such date he or she petitions the court for appointment as guardian.

I understand that I retain full parental rights even after the commencement of the standby guardian’s authority, and may revoke the standby guardianship at any time.

Parent: ___________________________ Date: __________

Witnesses. I declare that the person whose name appears above signed this document in my presence, or was physically unable to sign and asked another to sign this document, who did so in my presence. I further declare that I am at least eighteen years old and am not the person designated as standby guardian.

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

Before You Sign (Delete This Section)

• Count the days. For more than thirty days, complete every section, have the designee sign the consent, and sign Part A in front of a notary. For thirty days or less, names, signature and date are enough, but the full version does no harm.

• Check court orders. If a custody order requires both parents to agree on education or health decisions, both parents must consent. If any court order prohibits you from exercising this authority yourself, you cannot delegate it.

• School district. The designation does not move the child to the designee’s school district. Ask the designee’s district what it requires before the child changes schools.

• Give copies. Designee, school, pediatrician and health plan. If you revoke the designation, tell them directly.

• Standby guardian. Part B needs two adult witnesses who are not the standby guardian; it does not need a notary. You may file it with the county clerk for safekeeping.

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