Temporary Guardianship Consent Form

Minor Child(ren) Information

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

Parent/Legal Guardian Information

Parent/Guardian Name Contact Information

Temporary Guardian Information

Name of Temporary Guardian Relationship to Child(ren) Contact Information

Duration of Guardianship

Start Date

End Date

Authorization Details

Specific Powers or Limitations (if any) Additional Instructions (Optional)

Consent & Acknowledgment

I, the undersigned, hereby grant temporary guardianship of the above named child(ren) to the person listed as Temporary Guardian for the duration stated above.

Parent/Guardian Signature

Date

Temporary Guardian Signature

Date