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Temporary Guardianship Authorization for Care of Minor - DOC by dannya77

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Children

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									   Temporary Guardianship Authorization for Care of Minor

Child
Name: ______________________________
Permanent address:
________________________________________________________________________
________________________________________________________________________
Phone: ______________________________
Birthdate: ___________________________


Child's School or Day Care
[Leave this section blank if your child is not in school or any type of child care program.]
School or child care program: ___________________________ Grade (if in school): ___
Teacher: _____________________________
School address:
________________________________________________________________________
________________________________________________________________________
Phone: _______________________________


Other child care program (such as after-school program):
________________________________________________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Phone: _______________________________
Responsible adult: ______________________


Child's Doctor, Dentist, and Insurance
Doctor (or HMO): ______________________
Address:
________________________________________________________________________


                        Temporary Guardianship Authorization for Care of Minor    Page 1 of 5
________________________________________________________________________
Phone: ________________________________
Name of medical insurer/health plan: _______________________
Policy no.: _____________________________


Dentist: _______________________________
Address:
________________________________________________________________________
________________________________________________________________________
Phone: ________________________________
Name of dental insurer/dental plan: _________________________
Policy no.: _____________________________


Parents (or Legal Guardians)
Parent 1
Name: _________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Home phone: _____________________________ Work phone: ___________________
Cell phone or pager: _______________________               Email: ________________________


Parent 2
Name: _________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Home phone: _____________________________ Work phone: ___________________
Cell phone or pager: _______________________               Email: ________________________


Temporary Guardian



                       Temporary Guardianship Authorization for Care of Minor     Page 2 of 5
Name: _________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Home phone: _____________________________ Work phone: ___________________
Cell phone or pager: _______________________                Email: ________________________
Relationship to minor: _____________________________________________________


Emergency Contact
In case of emergency, if the guardian cannot be reached, please contact:
________________________________________________________________________
Home phone: _____________________________ Work phone: ___________________
Cell phone or pager: _______________________                Email: ________________________


              Authorization and Consent of Parent(s) or Legal Guardian(s)
    [If there is more than one parent, the use of the singular incorporates the plural.]
1. I affirm that I have
								
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