Temporary Legal Guardianship Appointment Consent

Child Full Name:
Date of Birth:
Address:
Parent(s)/Legal Guardian(s) Full Name(s):
Parent(s)/Legal Guardian(s) Address:
Phone Number(s):
Temporary Legal Guardian(s) Full Name(s):
Temporary Legal Guardian(s) Address:
Phone Number(s):
Period of Appointment:
From:
To:
Specific authorities and responsibilities granted:
Additional Instructions/Limitations (if any):
Parent/Guardian Signature
Date:
Parent/Guardian Signature
Date:
Temporary Legal Guardian Signature
Date: