School Guardianship Authorization Letter

Student Information

Student Name:

Date of Birth:

Grade/Class:

Student Address:

Parent/Legal Guardian Information

Name:

Phone Number:

Email:

Address:

Guardian Information

Name:

Relationship to Student:

Phone Number:

Email:

Guardian Address:

Authorization Statement

Effective Dates of Guardianship

From:

To:

Parent/Guardian Signatures

Parent/Legal Guardian Signature:

Date:

Appointed Guardian Signature:

Date:

Witness Name/Signature (if required):