Temporary Guardianship - The Purposeful Servants Cooperative

Parent/Legal Guardian & Children Information

Parent/Legal Guardian Name

First

Last

Parent/Legal Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Legal Guardian Phone Number

Temporary Date Temporary

Parent/Legal Guardian Email Address

Children Information

Include full name and date of birth for each child.

Temporary Guardian Information

Temporary Guardian Name

First

Last

Temporary Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Temporary Guardian Phone Number

Temporary Guardian Email Address

Temporary Guardian Relationship to Child(ren)

Example: Co-op member, Friend, Aunt, Uncle, Grandparent

Temporary Guardianship Details

Choose Type of Temporary Guardianship

Set a Start & End Date/Time
For a Specific Event

Temporary Guardianship Start Date/Time

Date

Time

This Temporary Guardianship shall be effective from this date/time.

Temporary Guardianship End Date/Time

Date

Time

This Temporary Guardianship shall terminate on this date/time.

Temporary Guardianship Activity/Event

This Temporary Guardianship shall be effective for the duration of the following specific activity/event.

Date(s) of Activity/Event

Location of Activity/Event

Temporary Guardianship Powers & Responsibilities

A. Emergency Medical Treatment: To authorize any necessary emergency medical, dental, or surgical treatment, including hospitalization, for the child(ren) when I cannot be reached in a timely manner. I understand that reasonable attempts will be made to contact me prior to such authorization. I agree to be responsible for all costs associated with such medical care.
B. General Care and Supervision: To provide general care, supervision, and discipline for the child(ren) during the specified duration, consistent with the standards of care that a prudent parent would exercise.
C. The Purposeful Servant Co-op Activities: To transport the child(ren) to and from scheduled The Purposeful Servant Co-op activities, field trips, and events. To make decisions regarding the child(ren)’s participation in such activities.
D. Other Specific Powers (if any): (e.g., administer prescribed medication, communicate with coop instructors regarding daily activities, etc.)

I, [Parent/Legal Guardian Name listed above], hereby grant to [Temporary Guardian Name listed above], the following powers and responsibilities regarding my child(ren) named above, for the specified duration selected.

Child's Medical Conditions/Allergies

List all per child as needed.

Medications

List all per child as needed.

Physician's Name and Phone Number

List all per child as needed.

Preferred Hospital/Urgent Care

List all per child as needed.

Health Insurance Provider and Policy Number

List all per child as needed.

Other Specific Powers

List all per child as needed. Examples: administer prescribed medication, communicate with coop instructors regarding daily activities, etc.

This Temporary Guardianship does NOT authorize the Temporary Guardian to:
– Make decisions regarding the child(ren)’s long-term educational curriculum.
– Consent to adoption.
– Change the child(ren)’s legal residence.
– Enroll the child(ren) in a new school.

Specific Limitations

List any and all other specific limitations not listed above.

Emergency Contacts

Emergency Contact 1 Name (Other than Temporary Guardian)

First

Last

In the event that neither the Parent/Legal Guardian nor the Temporary Guardian can be reached in an emergency, please contact this person.

Emergency Contact 1 Relationship to Child(ren)

Emergency Contact 1 Phone Number

Emergency Contact 2 Name (Other than Temporary Guardian)

First

Last

In the event that neither the Parent/Legal Guardian nor the Temporary Guardian can be reached in an emergency, please contact this person.

Emergency Contact 2 Relationship to Child(ren)

Emergency Contact 2 Phone Number

Acknowledgment and Signatures

Acknowledgement and Signatures of Legal Guardian

I, the undersigned Parent/Legal Guardian, hereby affirm that I have read, understood, and agree to the terms and conditions of this Temporary Guardianship Form. I authorize the named Temporary Guardian to act on my behalf as specified herein.

Signature of Legal Guardian

By typing your first and last name in this field you approve this is your signature.

Date of Legal Guardian Signature

Acknowledgement and Signatures of Temporary Guardian

I, the undersigned Temporary Guardian, hereby affirm that I have read, understood, and agree to accept the responsibilities outlined in this Temporary Guardianship Form.

Signature of Temporary Guardian

By typing your first and last name in this field you approve this is your signature.

Date of Temporary Guardian Signature