Emergency Guardianship Authorization

Date:

I,

authorize the following individual(s) to act as temporary guardians for my child/children in the event of an emergency:

Full Name(s) of Child(ren):

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

Name(s) of Authorized Guardian(s):

Contact Information of Authorized Guardian(s):

Duration of Authorization:

Special Instructions or Limitations:

Emergency Contact Information: