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TO ANY AND ALL: LAW ENFORCEMENT GENCIES SOCIAL WELFARE AGENCIES MEDICAL PROVIDERS SCHOOL DISTRICTS
RE:
DOB:
I, (Print Parent name) _________________________________, of Polk County, Florida, authorize
(Print name of temporary custodian) ____________________________________ to care for and have guardianship of the above listed child(ren). I authorize (Print name of temporary custodian) ________________________________, to provide medical, dental, psychological, and/or psychiatric treatment for the Child(ren); and to act in my stead and with my authority on the Child(ren)’s behalf and for the Child(ren)’s welfare. It is my intention, and I hereby direct, that in the event of my death or severe illness that my Child(ren), listed above, reside with (Print name of temporary custodian) __________________________________ and not leave their residence or the State of Florida without their written permission. I, (Print Parent name) _____________________________________, am giving this authority to (Print name of temporary custodian) ________________________________ freely and voluntarily. I, (Print name of temporary custodian) _____________________________________, understand and accept the authority (Print Parent name) __________________________________ is giving me to care for the above-named Child(ren).
___________________________________ (Print Parent name)
_____________________________________ (Print name of temporary custodian)
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___________________________________ (Signature of Parent)
_____________________________________ (Signature of temporary custodian)
___________________________________ (Print Witness name)
___________________________________ (Print Witness name)
___________________________________ (Signature of witness)
___________________________________ (Signature of witness)