Grandparent Temporary Guardianship Consent

Date:

Parent(s)/Legal Guardian(s) Name(s):

Child(ren) Full Name(s) and Date(s) of Birth:

Grandparent(s) Full Name(s):

Guardian(s) Address:

Parent(s)/Guardian(s) Contact Number:

Effective Dates of Temporary Guardianship:

From:

To:

Consent Statement

I/we, the undersigned, hereby give my/our consent and authorize the above-named grandparent(s) as temporary guardian(s) of my/our child(ren) named above for the period specified. They have full authority to make decisions regarding the care, medical treatment, and wellbeing of my/our child(ren) as necessary during this time.

Special Instructions / Medical Notes:

Parent/Guardian Signature:

Date:

Parent/Guardian Signature:

Date:

Witness Name: Witness Signature: Date: