Temporary Guardianship Agreement Template
This Temporary Guardianship Agreement (the “Agreement”) is entered into on [Effective Date], by and between:
Parent(s)/Legal Guardian(s): [Full Names], residing at [Address]
and
Temporary Guardian: [Full Name], residing at [Address].
Child Information:
• Full Name of Child: [Child’s Name]
• Date of Birth: [DOB]
1. Documentation and Evidence Packet [Module]
Document Item | Provided? (Y/N) | Identifier/Copy Location | Issued Date | Notes |
[Child ID/passport copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Insurance card copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[School contact sheet] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Medical notes/allergy list] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
Document Item | Provided? (Y/N) | Identifier/Copy Location | Issued Date | Notes |
[Child ID/passport copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Insurance card copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[School contact sheet] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Medical notes/allergy list] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
Document Item
Provided? (Y/N)
Identifier/Copy Location
Issued Date
Notes
[Child ID/passport copy]
[Y/N]
[File/Link]
[MM/DD/YYYY]
[Notes]
[Insurance card copy]
[School contact sheet]
[Medical notes/allergy list]
2. Grant of Temporary Guardianship
2.1 Parent(s) voluntarily grant temporary guardianship to Temporary Guardian for the duration stated below.
2.2 Authority: Decisions regarding care, medical treatment, education, and general welfare, subject to limitations recorded in this Agreement.
3. Duration
3.1 Start Date: [Start Date]
3.2 End Date: [End Date]
3.3 Early Termination: [Written notice method and effective time]
4. Rights and Responsibilities
4.1 Routine Decisions: Temporary Guardian may make routine decisions regarding daily care, education, and activities.
4.2 Medical Decisions: Temporary Guardian may authorize medical or dental care, including emergency decisions.
4.3 Education Decisions: Temporary Guardian may [enroll/access records/communicate] as needed.
5. Parental Rights and Retrieval
5.1 Retained Rights: This Agreement does not terminate parental rights.
5.2 Retrieval Procedure: [Pickup plan/identification requirements/notice]
5.3 Parent Updates: [Schedule/method]
Parent’s phone: [Parent’s Phone Number]
Temporary Guardian’s phone: [Guardian’s Phone Number]
Secondary Contact: [Name/Phone/Email]
7. Governing Law
7.1 This Agreement shall be governed by the laws of the State of Washington.
Signatures
Parent/Legal Guardian: _________________________ Date: ____________
Printed Name: ___________________________
Parent/Legal Guardian [If Applicable]: _________________________ Date: ____________
Temporary Guardian: _________________________ Date: ____________
Printed Name: ______________________________
Reviewed By [Optional]: _________________________ Date: ____________
Printed Name/Role: ______________________________
Document Item | Provided? (Y/N) | Identifier/Copy Location | Issued Date | Notes |
[Child ID/passport copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Insurance card copy] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[School contact sheet] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |
[Medical notes/allergy list] | [Y/N] | [File/Link] | [MM/DD/YYYY] | [Notes] |