Temporary Guardianship Letter (Sample) Template

Date: [Date]

To Whom It May Concern,

1. Parent/Legal Guardian Information

I, [Parent/Guardian Full Name], am the ☐ mother ☐ father ☐ legal guardian of [Child Full Legal Name], born on [Child Date of Birth].
My address is: [Parent Address].
My phone/email: [Phone] / [Email].

2. Temporary Guardian Information

I authorize [Temporary Guardian Full Name], born on [DOB optional], residing at [Address], phone/email: [Contact], to act as the temporary caregiver for my child.

3. Term of Authorization

This authorization begins on [Start Date] and ends on [End Date], unless revoked earlier in writing.

4. Authority Granted

During the authorized period, I give the Temporary Guardian permission to:

• Provide day-to-day care and supervision

• Communicate with the child’s school and sign routine school forms

• Consent to routine medical care and emergency medical treatment if I cannot be reached

• Travel with the child (if applicable): [Destinations/dates]

5. Medical and Emergency Information (Optional)

• Child’s doctor/clinic: [Name/phone]

• Insurance: [Provider/policy]

• Allergies/medications: [List]

• Emergency contact: [Name/phone]

6. Additional Notes (Optional)

[Any limitations, special instructions, or custody notes.]

Sincerely,
[Parent/Guardian Full Name]

Signatures

Parent/Guardian: [Full Name]
Date: [Date]
Signature: ___________________________

Temporary Guardian (Acknowledgment, Optional): [Full Name]
Date: [Date]
Signature: ___________________________

Witnesses (If Required)

Witness #1 Name: [Name]
Date: [Date]
Signature: ___________________________

Witness #2 Name: [Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (Optional)

State of [State]
County of [County]

On [Date], before me, [Notary Name], personally appeared [Parent/Guardian Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this document, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________