Temporary Custody Agreement

This agreement is made on by and between: Custodial Parent/Guardian Name Address and Temporary Custodian Name Address

Child(ren) Information

Full Name(s) of Child(ren) Date of Birth

Agreement Details

Start Date of Temporary Custody End Date of Temporary Custody Purpose/Reason for Temporary Custody

Authority Granted

Parent/Guardian Signature

Date

Temporary Custodian Signature

Date