Authorization For Temporary Guardianship Of Minor
ADVERTISEMENT
1
2
3AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR
Child
Full Legal Name:_______________________________________________________________
Date of Birth: _______________________ Age: ___________ Gender: ___________
Doctor’s Information
Doctor’s Name: ________________________________________________________________
Doctor’s Address: ______________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: _______________
Medical Insurer/Health Plan: __________________________ Policy #: ___________________
Allergies to Medications: _________________________________________________________
Allergies (Other): _______________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_____________________________________________________________________________
Note any other significant medical information:
_____________________________________________________________________________
_____________________________________________________________________________
Dentist’s Information
Dentist’s Name: ________________________________________________________________
Dentist’s Address: ______________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: ______________
Dentist’s Insurer/Health Plan: __________________________ Policy #: ____________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name:________________________________________________________________________
Address: ______________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: ____________________________________________________
_____________________________________________________________________________
Parent #2:
Name:________________________________________________________________________
Address: ______________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: ____________________________________________________
_____________________________________________________________________________
Temporary Guardian(s):
Temporary Guardian #1:
Name: _______________________________________________________________________
Address: ______________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: ____________________________________________________
_____________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal