Power of Attorney Delegating Parental Powers (Washington)
Temporary Guardianship Form under RCW 11.130.145 and RCW 11.125.410
This power of attorney lets the parent named below delegate powers regarding the care and custody of a child to a trusted adult for a limited time. It is not a court order and does not appoint a guardian; in Washington a guardian of a minor can be appointed only by a court. It delegates only the signing parent’s own powers and does not affect the rights of the other parent or any parenting plan.
1. Parent (Principal)
Name: [Full Legal Name]
Address: [Street, City, Washington ZIP] · Phone: [Phone] · Email: [Email]
Second parent (if also delegating): [Full Legal Name, Address, Phone]
2. Agent (Caregiver)
Name: [Full Legal Name]
Relationship to child: [Grandparent / aunt / uncle / adult sibling / family friend / other]
Address: [Street, City, State ZIP] · Phone: [Phone]
Alternate agent (optional, if the agent cannot act): [Full Legal Name, Address, Phone]
3. 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”] |
4. Term
This power of attorney takes effect on [Start Date] and ends on [End Date], which is not more than twenty-four months after it takes effect (RCW 11.130.145), unless I revoke it earlier.
5. Powers Delegated
Under RCW 11.130.145, I delegate to my agent the following powers regarding the care and custody of my child (check all that apply):
☐ Daily care, supervision and residence of the child with the agent
☐ School matters: enrollment, attendance, conferences, records, permission slips and activities
☐ Extracurricular activities, sports, camps and child care arrangements
☐ Travel with the child within Washington ☐ within the United States (a separate travel consent letter is attached for air travel)
☐ Applying for and receiving benefits for the child
☐ Other: [Describe]
I do not delegate the power to consent to the child’s marriage or adoption, which the law does not allow a parent to delegate. Other limits: [for example, no change of the child’s school district without my written consent].
6. Health Care Decisions (RCW 11.125.410; RCW 7.70.065)
I authorize my agent to make health care decisions, including decisions about mental health care, for my child. This is my signed authorization to make health care decisions for the child within the meaning of RCW 7.70.065(2)(a)(iv). ☐ This authority applies only when I cannot be reached. ☐ This authority applies whenever the child is in the agent’s care.
Except in an emergency, the agent will contact me before consenting to: [for example, non-emergency surgery or new psychiatric medication].
Health insurance: [Insurer, member ID, group number] · Pediatrician: [Name, Phone] · Current medications: [List]
7. Nomination of Guardian (Optional; RCW 11.125.410(2))
If a court needs to appoint a guardian of the person of my child, I nominate [Name] (alternate: [Name]) as guardian, to serve ☐ during my disability ☐ during the child’s minority ☐ until [Date].
[A court appointing a guardian for a minor must appoint a person a parent nominated in a probated will or other record, such as a sworn declaration or power of attorney, unless the appointment is contrary to the child’s best interest (RCW 11.130.215).]
8. Revocation
I may revoke this power of attorney at any time by written notice to the agent. I will also notify the child’s school and health care providers who received a copy.
9. Signatures
Parent: ___________________________ Date: __________
Second parent (if delegating): ___________________________ Date: __________
Acceptance by agent. I accept this delegation and agree to act in the child’s best interest.
Agent: ___________________________ Date: __________
Complete ONE of the following (RCW 11.125.050):
Option A. Notary acknowledgment
State of Washington, County of [County]
This record was acknowledged before me on [date] by [name(s) of parent(s)].
___________________________
Notary Public, State of Washington · My commission expires: [ ]
Option B. Two witnesses
We declare that the parent signed and dated this power of attorney in our presence, and that each of us is competent, is not a home care provider for the parent or a care provider at an adult family home or long-term care facility where the parent lives, and is not related to the parent or the agent by blood, marriage or state registered domestic partnership.
Witness 1: ___________________________ Printed name and address: [ ]
Witness 2: ___________________________ Printed name and address: [ ]
Before You Sign (Delete This Section)
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Notary or witnesses. Use a notary if you can: a notarized signature is presumed genuine. Witnesses must be unrelated to you and to the agent.
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24 months at most. For a longer arrangement, or if you may not be able to resume care, ask the court about a guardianship or a standby guardian (RCW 11.130.220).
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Parenting plans. If a parenting plan or court order governs the child, check it first: this document cannot give the agent more authority than you have.
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Give copies. Agent, school, pediatrician and health plan. Keep the original.
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Travel. For flights, especially international ones, add a separate child travel consent letter signed by both parents.