Texas Temporary Guardianship Form: Authorization Agreement for Nonparent Adult Caregiver

Authorization Agreement for Nonparent Adult Caregiver (Texas)

Temporary Guardianship Form under Chapter 34, Texas Family Code

Important Warnings and Disclosures — Read Before Signing

1. This authorization agreement is an important legal document.

2. The parent and the adult caregiver must read all of these warnings and disclosures before signing it.

3. The persons signing this agreement are not required to consult an attorney but are advised to do so.

4. The parent’s rights as a parent may be adversely affected by placing or leaving the parent’s child with another person.

5. This agreement does not confer on the adult caregiver the rights of a managing or possessory conservator or legal guardian.

6. A parent who is a party to this agreement may terminate it and resume custody, possession, care and control of the child on demand, and at any time the parent may request the return of the child.

7. Failure by the adult caregiver to return the child to the parent immediately on request may have criminal and civil consequences.

8. Under other applicable law, the adult caregiver may be liable for certain expenses relating to the child in the adult caregiver’s care, but the parent still retains the parental obligation to support the child.

9. In certain circumstances, this agreement may not be entered into without written permission of the court.

10. This agreement may be terminated by certain court orders affecting the child.

11. This agreement does not supersede, invalidate or terminate any prior authorization agreement regarding the child.

12. This agreement is void if a prior authorization agreement regarding the child is in effect and has not expired or been terminated.

13. Except as provided by Section 34.005(a-2), Texas Family Code, this agreement is void unless, not later than the 10th day after the date it is signed, the parties mail to a parent who was not a party to it, at that parent’s last known address, if the parent is living and the parent’s parental rights have not been terminated: one copy by certified mail, return receipt requested, or international registered mail, return receipt requested, as applicable; and one copy by first-class mail or international first-class mail, as applicable.

14. This agreement does not confer on the adult caregiver the right to authorize the performance of an abortion on the child or the administration of emergency contraception to the child.

1. Adult Caregiver

Name: [Full Legal Name]
Relationship to the child: [Grandparent / aunt / uncle / adult sibling / family friend / other]
Current physical address: [Street, City, Texas ZIP]
Telephone number or best way to contact: [Phone, email]

2. Parent(s)

Parent: [Full Legal Name]
Current address: [Address] · Telephone or best way to contact: [Phone, email]

Other parent: [Full Legal Name]
Current address: [Address] · Telephone or best way to contact: [Phone, email]
☐ The other parent also signs this agreement. ☐ The other parent does not sign; a copy will be mailed as described in Section 8.

3. Child

Name: [Full Legal Name] · Date of birth: [Date]
[Add a line for each child, or use a separate agreement for each child.]

4. Authorization

The parent authorizes the adult caregiver to perform the following acts regarding the child (Section 34.002(a), Texas Family Code):

(1) authorize medical, dental, psychological or surgical treatment and immunization of the child, including executing any consents or authorizations for the release of information as required by law relating to the treatment or immunization;
(2) obtain and maintain health insurance coverage for the child and automobile insurance coverage for the child, if appropriate;
(3) enroll the child in a day-care program or preschool or in a public or private elementary or secondary school;
(4) authorize the child to participate in age-appropriate extracurricular, civic, social or recreational activities, including athletic activities;
(5) authorize the child to obtain a learner’s permit, driver’s license or state-issued identification card;
(6) authorize employment of the child;
(7) apply for and receive public benefits on behalf of the child; and
(8) obtain copies or originals of state-issued personal identification documents for the child, including the child’s birth certificate, and, to the extent authorized under federal law, copies or originals of federally issued personal identification documents for the child, including the child’s social security card.

The adult caregiver has been given authorization to perform these functions as a result of a voluntary action of the parent, and the adult caregiver has voluntarily assumed the responsibility of performing them.

Parent’s instructions for the caregiver (optional, for example medical conditions, school, contact schedule): [ ]

5. Statements of the Parent and the Adult Caregiver

(a) Neither the parent nor the adult caregiver has knowledge that a parent, guardian, custodian, licensed child-placing agency or other authorized agency asserts any claim or authority inconsistent with this agreement with regard to actual physical possession or care, custody or control of the child.

(b) Check one:
☐ To the best of the parent’s and the adult caregiver’s knowledge, there is no court order or pending suit affecting the parent-child relationship concerning the child; there is no pending litigation in any court concerning custody, possession or placement of the child, or access to or visitation with the child; and a court does not have continuing jurisdiction concerning the child.
☐ The court with continuing jurisdiction concerning the child has given written approval for the execution of this agreement. County in which the court is located: [ ] · Number of the court: [ ] · Cause number in which the order was issued or the litigation is pending: [ ]. A copy of the written approval is attached.

(c) To the best of the parent’s and the adult caregiver’s knowledge, there is no current, valid authorization agreement regarding the child.

(d) This authorization is made in conformance with Chapter 34, Texas Family Code.

(e) The parent and the adult caregiver understand that each party to this agreement is required by law to immediately provide to each other party information regarding any change in the party’s address or contact information.

6. Term and Termination

The parent states that this agreement is for a term of (check one):
☐ six months from the date the parties enter into it, renewing automatically for six-month terms unless it is terminated as provided by Section 34.008, Texas Family Code; or
☐ the time stated here, with an expiration date earlier than six months after the date the parties enter into it: [Date].

The parent identifies the following circumstances under which this agreement may be:

(a) terminated before its term expires (Section 34.008): if a court enters an order affecting the parent-child relationship; concerning custody, possession or placement of the child; concerning access to or visitation with the child; or regarding the appointment of a guardian for the child under Subchapter B, Chapter 1104, Estates Code; or if a party revokes it in writing, gives each party written notice of the revocation, and files the written revocation with the clerk of the county in which the child resides, the child resided when this agreement was executed, or the adult caregiver resides, and with the clerk of each court described in Section 34.008(c)(3). If both parents signed this agreement, either parent may revoke it without the other parent’s consent.

(b) continued by a court (Section 34.008(b)): if the court entering an order described in (a) gives written permission for this agreement to continue.

7. Signatures (Sworn Before a Notary Public)

Parent: ___________________________ Date: __________
Printed name: [ ]

Other parent (if signing): ___________________________ Date: __________
Printed name: [ ]

Adult caregiver: ___________________________ Date: __________
Printed name: [ ]

State of Texas, County of [County]

Sworn to and subscribed before me on [date] by [names of parent(s) and adult caregiver].

___________________________
Notary Public, State of Texas
My commission expires: [ ]
[Seal]

8. Certificate of Mailing to the Parent Who Did Not Sign

[Complete within 10 days after signing if only one parent signed, unless the exception in Section 34.005(a-2) applies.]

On [date], one copy of this executed agreement was mailed to [name of other parent] at [last known address] by ☐ certified mail, return receipt requested ☐ international registered mail, return receipt requested (tracking number [ ]), and one copy by ☐ first-class mail ☐ international first-class mail.

Signed: ___________________________ (parent or adult caregiver)

Revocation (Keep Separately Until Needed)

I, [Name], a party to the authorization agreement for nonparent adult caregiver regarding [child’s name], executed on [date], revoke that agreement effective [date]. I have given each party written notice of this revocation and will file it with the county clerk of [County] County [and with the clerk of each court described in Section 34.008(c)(3), Texas Family Code].

Signed: ___________________________ Date: __________

Before You Sign (Delete This Section)

• Sign in front of a notary. The parent and the adult caregiver both sign and swear to the agreement before a notary public (§ 34.004(a)). Schools and doctors who rely on the agreement in good faith are protected only if it is completed as chapter 34 requires (§ 34.007(a)).

• Mail the other parent within 10 days. If only one parent signs, send one copy by certified mail, return receipt requested, and one by first-class mail to the other parent’s last known address, and keep the receipts. Skipping this makes the agreement void (§ 34.005(a-1)), unless that parent has no court-ordered possession or access and has committed family violence or assault documented by a protective order or a conviction (§ 34.005(a-2)).

• Court case? Get a written order first. If there is a custody order, a pending custody or visitation case, or a court with continuing, exclusive jurisdiction over the child, the parent needs a written order from that court before signing; otherwise the agreement is void (§ 34.004(b), (c)).

• One agreement at a time. A new agreement does not cancel an old one, and one signed while another is in effect is void (§§ 34.002(d), 34.008(f)). Revoke and file the old one first.

• Keep contact details current. Each party must immediately tell the others about a new address or phone number; otherwise the agreement becomes voidable by the other party (§ 34.005(b)).

• 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.