Childcare Temporary Guardianship Agreement

Effective Date:

Parent(s)/Legal Guardian(s):

Child(ren):

Date(s) of Temporary Guardianship:

Temporary Guardian(s):

Address of Temporary Guardian(s):

Phone Number(s) of Temporary Guardian(s):

Authorization

I/we, the Parent(s)/Legal Guardian(s) named above, hereby grant temporary guardianship of the above-named child(ren) to the Temporary Guardian(s) named above for the date(s) specified. The Temporary Guardian(s) is/are authorized to provide for the care, custody, and control of the child(ren), and to make any and all decisions regarding their health, education, and welfare, including medical and dental care, during this period.

Special Instructions/Allergies/Medical Conditions:

Parent/Legal Guardian Signature & Date

Temporary Guardian Signature & Date