Short-Term Guardianship Transfer Agreement
Date:
Child's Information
Full Name:
Date of Birth:
Address:
Parent(s)/Legal Guardian(s) Information
Full Name(s):
Address:
Phone Number:
Temporary Guardian(s) Information
Full Name(s):
Address:
Phone Number:
Guardianship Term
Start Date:
End Date:
Authorization Details
Specific Powers/Instructions:
Medical Information
Medical Concerns/Allergies:
Health Insurance Details:
Parent/Legal Guardian Signature:
Date:
Temporary Guardian Signature:
Date: