We, the undersigned parents, ____________________ and _________________, of
_________________________ ______________, ______ _______, hereby grant
____________________________ and _____________________________________, of
_________________________ ______________, ______ _______, the authority to take
temporary care of the following child(ren): _______________________________________.
This grant of temporary authority shall begin on __________________________, and shall remain
effective until terminated by the undersigned.
The above named caretaker(s) shall have the power to:
- seek appropriate medical treatment or attention on behalf of the child(ren) as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits
- authorize medical treatment or medical procedures in an emergency situation
- make appropriate decisions regarding clothing, bodily nourishment, and shelter
- explain absences from school
- sign release forms for sports
- sign release forms for field trips
Dated: ________________________________
________________________________________
Print Name _______________________________
________________________________________
Print Name _______________________________