Temporary Parental Consent Agreement
1. I am/We are the parent(s) of
[child’s name], born on _______________
[birth date]. I am/We are 18 years old or older.
2. I/We hereby give consent for
[child’s name] to remain in the residential care of
__________________________________________ [caregiver’s name and relationship
to the child] who live(s) at
[street, city, state]. The caregiver’s phone number is:
_______________________.
3. I/We hereby authorize this caregiver to have the care and control of the child, to
make health care decisions for the child, to have the authority to get and provide all
necessary care, including emergency and routine medical and dental care, evaluations
and treatment, and to make all necessary childcare and educational arrangements for
the child while the child is in her/his/their care with the following restrictions:
. I/We authorize the above named caregiver(s) to make decisions on all other
issues regarding the child [examples: religious decisions, decisions about the child’s
social life, decisions about the child’s school activities, and personal care decisions
(haircuts, pierced ears, and so on)] with the following restrictions:
.
4. I/We authorize this caregiver to take the child out of state for travel with the
following restrictions:
.
5. This agreement lasts until _____________________ [put an end date or
“indefinitely”], unless it is revoked before it expires. Either parent can revoke this
consent and terminate this agreement at any time by delivering to the caregiver a
signed, written notice at least a week in advance.
6. (The following paragraph applies if only one parent is available to consent) [ ] I
am the child’s sole custodian. The other parent has not signed this consent because
[explain whether the other parent is unknown or absent]
_____
7. Additional items:
____________________________________
_______________________________
Child’s Parent/Caregiver Child’s Parent/Caregiver
This form does not need to be notarized to be valid.
SUBSCRIBED AND SWORN TO before me this ____ day of ____________ 20 .
NOTARY PUBLIC in and for the State of Washington, residing at
My commission expires:
By __________________________________________
_____________________________________________
Notary Signature
AGREED:
____________________________ Date: _______________
Parent/Caregiver
____________________________ Date: _______________
Parent/Caregiver
