Child Care Authorization (Temporary Guardianship) Form Template

Child Care Authorization (Temporary Guardianship) Form

1. 1. 1. Parent or Legal Guardian and Child

   I am, or we are, the parent or legal guardian of the child named below and I sign this Child Care Authorization (this "Authorization") to delegate caregiving authority as described. PARENT OR GUARDIAN ONE: [PARENT ONE FULL NAME], date of birth [PARENT ONE DATE OF BIRTH], address [PARENT ONE ADDRESS], telephone [PARENT ONE PHONE], email [PARENT ONE EMAIL], identification type and number [PARENT ONE ID]. PARENT OR GUARDIAN TWO: [PARENT TWO FULL NAME], date of birth [PARENT TWO DATE OF BIRTH], address [PARENT TWO ADDRESS], telephone [PARENT TWO PHONE], email [PARENT TWO EMAIL], identification type and number [PARENT TWO ID]. CHILD: [CHILD FULL NAME], date of birth [CHILD DATE OF BIRTH], place of birth [CHILD PLACE OF BIRTH], current address [CHILD ADDRESS], Social Security number on file with [RECORD HOLDER]. If more than one child is covered, each is listed on the attached Schedule of Children signed by the same parents or guardians. If only one parent signs, the reason is: [SOLE SIGNATORY REASON, e.g., sole legal custody under an order dated [ORDER DATE]; the other parent is deceased; the other parent cannot be located].

2. 2. 2. Designated Caregiver

   I appoint the following person as the temporary caregiver of the child (the "Caregiver"): [CAREGIVER FULL NAME], date of birth [CAREGIVER DATE OF BIRTH], address where the child will reside [CAREGIVER ADDRESS], home telephone [CAREGIVER HOME PHONE], mobile telephone [CAREGIVER MOBILE PHONE], email [CAREGIVER EMAIL], relationship to the child [CAREGIVER RELATIONSHIP], identification type and number [CAREGIVER ID]. If the Caregiver is unable or unwilling to serve, I appoint [ALTERNATE CAREGIVER FULL NAME], address [ALTERNATE CAREGIVER ADDRESS], telephone [ALTERNATE CAREGIVER PHONE], relationship [ALTERNATE CAREGIVER RELATIONSHIP], to serve in that role on the same terms. Only one Caregiver may act at a time. The Caregiver may not delegate this authority to another person, except that the Caregiver may leave the child with a babysitter, school, or child care provider for ordinary short periods.

3. 3. 3. Duration of the Authorization

   This Authorization is effective from [START DATE] and continues until [END DATE], or until it is revoked earlier under Section 9, whichever occurs first. The reason for the delegation is [REASON, e.g., military deployment, hospitalization and recovery, extended work travel, participation in a treatment program, a temporary family emergency]. I understand that state law may limit how long caregiving authority can be delegated by a signed document without a court order, commonly to a period such as six months or one year, and that a longer or indefinite arrangement may require a guardianship proceeding. If I am unable to resume care by the end date, I will either sign a new authorization or begin the process required by my state. This Authorization may be extended only by a new signed and notarized document.

4. 4. 4. Scope of Authority Granted

   I authorize the Caregiver to provide for the daily care, custody, supervision, and control of the child during the period stated above, and specifically to: house and feed the child and provide appropriate supervision; transport the child, including in a motor vehicle, and arrange transportation to and from school and activities; enroll the child in and consent to participation in school activities, sports, camps, lessons, religious activities, and field trips, including signing waivers and permission slips required for them; obtain and hold identification documents and records of the child needed for daily care; sign for deliveries and receive mail relating to the child; make decisions about routine discipline, screen time, curfews, and household rules consistent with the instructions in Section 8; consent to routine haircuts, dental cleanings, and eye examinations; and take any other action reasonably necessary for the health, safety, education, and welfare of the child. The Caregiver will exercise this authority in accordance with my known wishes and in the best interests of the child.

5. 5. 5. Medical, Dental, and Mental Health Consent

   I authorize the Caregiver to consent on my behalf to medical, dental, surgical, hospital, emergency, vision, and mental health care for the child, including examinations, diagnostic testing, anesthesia, immunizations, prescribed medication, and treatment recommended by a licensed provider. I authorize any physician, dentist, hospital, clinic, pharmacy, or other provider to examine and treat the child on the consent of the Caregiver and to disclose to the Caregiver the health information of the child necessary for that treatment, and I intend the Caregiver to be treated as an authorized personal representative for that purpose. The medical information for the child is: allergies [ALLERGIES], current medications and dosages [MEDICATIONS], medical and mental health conditions [CONDITIONS], immunization status [IMMUNIZATIONS], dietary restrictions [DIETARY RESTRICTIONS], and blood type [BLOOD TYPE]. The primary physician is [PHYSICIAN NAME], telephone [PHYSICIAN PHONE]; the dentist is [DENTIST NAME], telephone [DENTIST PHONE]. Health insurance coverage is with [INSURER NAME], policy number [POLICY NUMBER], group number [GROUP NUMBER], and the insurance card [IS / IS NOT] in the possession of the Caregiver. The Caregiver will notify me before authorizing any non-emergency procedure and as soon as possible after any emergency treatment.

6. 6. 6. School and Educational Authority

   I authorize the Caregiver to act on my behalf in educational matters for the child, including: enrolling the child in or maintaining enrollment at [SCHOOL NAME AND ADDRESS]; communicating with teachers, counselors, coaches, and administrators; attending conferences, meetings, and school events; receiving report cards, notices, and disciplinary communications; signing permission slips, activity waivers, and technology agreements; picking the child up from school and adding or removing authorized pickup persons on my written instruction; and accessing the education records of the child, and I authorize the school to release those records to the Caregiver. The Caregiver [SPECIAL EDUCATION ELECTION, e.g., MAY / MAY NOT] participate in and consent to decisions in a special education or individualized education program process on my behalf. Any change of school, withdrawal from school, or homeschooling decision requires my written consent and is not authorized by this document.

7. 7. 7. Financial Responsibility and Support

   I remain financially responsible for the child during the period of this Authorization, including the cost of food, clothing, school fees, activities, medical treatment, and transportation. I will provide the Caregiver with [SUPPORT ARRANGEMENT, e.g., $[AMOUNT] per month paid on the [DAY] of each month by [PAYMENT METHOD]] and will reimburse reasonable additional expenses on presentation of receipts within [REIMBURSEMENT PERIOD, e.g., thirty days]. The Caregiver is not authorized to incur an expense above [EXPENSE APPROVAL THRESHOLD] on my behalf without contacting me first, except where the expense is necessary for the health or safety of the child. The Caregiver is not authorized to open a financial account in the name of the child, apply for public benefits in the name of the child, borrow against any asset of the child, or represent to any person that the Caregiver has a financial interest in the child, except as follows: [BENEFITS AUTHORIZATION, if any]. Any funds or benefit payments provided for the child will be used solely for the needs of the child, and the Caregiver will keep records of them.

8. 8. 8. Instructions, Contact With the Parent, and Emergency Contacts

   My specific instructions for the care of the child are: [CARE INSTRUCTIONS, e.g., daily routine, bedtime, dietary and religious observances, permitted activities, screen time and device rules, discipline preferences, and contact with named relatives]. The child will have contact with me by [PARENT CONTACT METHOD] at least [CONTACT FREQUENCY], and the Caregiver will not restrict or discourage that contact. The Caregiver will notify me immediately of any injury, illness requiring treatment, disciplinary incident at school, contact from any government agency, or change of address. I may be reached at [PARENT CONTACT DETAILS DURING PERIOD], and if I cannot be reached, contact [EMERGENCY CONTACT NAME], relationship [EMERGENCY CONTACT RELATIONSHIP], telephone [EMERGENCY CONTACT PHONE]. Other adults authorized to have contact with or pick up the child are: [AUTHORIZED PERSONS]. The following persons are not authorized to have contact with or pick up the child: [PERSONS NOT AUTHORIZED].

9. 9. 9. Limitations, Retained Parental Rights, and Revocation

   This Authorization does not transfer legal custody or guardianship of the child, does not terminate or suspend my parental rights, and does not create a permanent arrangement. The Caregiver may NOT: consent to the adoption, marriage, emancipation, or military enlistment of the child; consent to an abortion or sterilization procedure; change the legal residence of the child to another state or country or take the child out of the country without my separate written consent; apply for a passport or other identity document for the child; initiate or settle any legal claim on behalf of the child; consent to the child obtaining a tattoo, piercing, or driver license; or agree to any long-term commitment on behalf of the child extending beyond the end date of this Authorization. I retain all parental rights, may see and communicate with the child at any time, may direct the actions of the Caregiver, and may revoke this Authorization at any time by written notice delivered to the Caregiver, with a copy to the school and health care providers who have been given this document. On revocation or expiry, the Caregiver will promptly return the child to me together with all documents, records, medication, insurance cards, and belongings of the child.

10. 10. 10. Caregiver Acceptance

    By signing below, the Caregiver accepts this appointment and agrees to: care for the child in accordance with this Authorization and the instructions of the parent; provide a safe, stable, and appropriate home; ensure the child attends school regularly and receives necessary medical care; keep the parent informed as required by Section 8; use funds provided solely for the needs of the child and keep records of them; not hold the child out as the legal child or ward of the Caregiver; and return the child to the parent promptly on request, on revocation, or on the end date. The Caregiver confirms that the residence where the child will stay is suitable, that all adults residing there are known to the parent, and that the Caregiver will notify the parent before any additional adult moves into the residence. The Caregiver may resign by giving the parent [CAREGIVER NOTICE PERIOD, e.g., fourteen days] written notice, or immediately in an emergency, and will care for the child until the parent or the alternate caregiver takes over.

11. 11. 11. Reliance, Governing Law, and Signatures

    Any school, physician, dentist, hospital, clinic, pharmacy, insurer, child care provider, camp, activity provider, or other person may rely on this Authorization and on the Caregiver acting under it, without further inquiry and without liability, unless that person has actual notice that it has been revoked or has expired. A photocopy, scanned copy, or electronic copy of this signed document has the same effect as the original. This Authorization is governed by the laws of the State of [GOVERNING STATE]. PARENT OR GUARDIAN ONE: [PARENT ONE FULL NAME]. Signature: ______________________. Date: [DATE]. PARENT OR GUARDIAN TWO: [PARENT TWO FULL NAME]. Signature: ______________________. Date: [DATE]. CAREGIVER: [CAREGIVER FULL NAME]. Signature: ______________________. Date: [DATE]. State of [STATE], County of [COUNTY]. On [NOTARY DATE], before me personally appeared the above-named signers, known to me or satisfactorily identified, who acknowledged that they signed this document as their free and voluntary act. Notary Public: ______________________. My commission expires: [EXPIRATION DATE].

12. 12. Disclaimer

    This template is provided for general informational purposes only and is not legal advice. Delegating caregiving authority over a child is governed by state law, and the rules differ substantially: many states allow a parent to delegate by a signed, notarized document for a limited period such as six months or a year, some require a specific statutory form, and some require a court proceeding for anything beyond short-term care. This document does not create legal guardianship, does not transfer custody, and does not bind a court. Where a custody order exists, its terms control and the other parent may need to consent. Schools, hospitals, and public benefit agencies may apply their own requirements. Have this document reviewed by a licensed family law attorney in your state before relying on it. Use of this template does not create an attorney-client relationship with ScanContract.