Temporary Guardianship Agreement

Date:

Parent/Legal Guardian Information

Name:

Address:

Phone Number:

Email:

Child Information

Child's Name:

Date of Birth:

Temporary Guardian Information

Name:

Address:

Phone Number:

Email:

Agreement Period

Start Date:

End Date:

Authorization

Details of permissions and responsibilities granted to the temporary guardian:

Parent/Legal Guardian Signature

Printed Name:

Date:

Temporary Guardian Signature

Printed Name:

Date: