Emergency Legal Guardian Authorization Form

Child’s Information

Full Name: Date of Birth: Address:

Parent(s)/Legal Guardian(s) Information

Name(s): Phone Number(s): Email Address(es): Address:

Authorized Temporary Guardian

Name: Relationship to Child: Phone Number: Address:

Authorization Details

Start Date: End Date: Specific powers or limitations (if any):

Medical Information

Allergies or Special Medical Conditions: Primary Physician Name & Contact: Insurance Provider & Policy Number:

I/We authorize the above-named temporary guardian to act on our behalf in matters of emergency for the child named above, including obtaining medical care if needed, during the specified dates.