Date: [Date]
To Whom It May Concern,
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].
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:
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Provide day-to-day care and supervision
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Communicate with the child’s school and sign routine school forms
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Consent to routine medical care and emergency medical treatment if I cannot be reached
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Travel with the child (if applicable): [Destinations/dates]
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]
-
Child’s doctor/clinic: [Name/phone]
-
Insurance: [Provider/policy]
-
Allergies/medications: [List]
-
Emergency contact: [Name/phone]
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): ___________________