CHILD GUARDIAN CONSENT FORM
I ____________________ of _________________________________, the current legal parent of
(child's parent) (parent's city & state)
_______________________ born on ___________________________________, hereby appoint
(child's name) (child's date of birth)
_____________________ of _________________________________ as legal guardian for my child
(guardian's name) (guardian's city and state)
for the period of time beginning on ___________________ and ending on ____________________.
The guardian shall have the right to:
1. Determine and authorize necessary medical attention.
2. Provide necessary clothing, food, and shelter.
3. Generally act in loco parentis.
Executed this ________ day of ____________________, ________
____________________________________
(Parent's Signature)
State of ______________________
County of ______________________
On this ______ day of ____________________, _____, before me, the undersigned, a Notary Public in and for the
State and County mentioned above, personally appeared __________________________, known to me or
satisfactorily proven to be the person who executed the foregoing instrument, and who have acknowledged the
execution of the same.
Subscribed and sworn to before me this _____ day of _________________,______.
My Commission Expires:
_____________________________
_____________________
NOTARY PUBLIC

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