APPOINTMENT OF SHORT-TERM GUARDIAN OF A MINOR

IT IS IMPORTANT TO READ THE FOLLOWING INSTRUCTIONS:

By properly completing this form, a parent or the guardian of the person of the child is
appointing a guardian of a child of the parent (or a minor ward of the guardian, as the case may
be) for a period of up to 60 days. A separate form should be completed for each child. The person
appointed as the guardian must sign the form, but need not do so at the same time as the parent or
parents or guardian.
This form may not be used to appoint a guardian if there is a guardian already appointed for
the child, ecept that if a guardian of the person of the child has been appointed, that guardian
may use this form to appoint a short!term guardian. Both li"ing parents of a child may together
appoint a guardian of the child, or the guardian of the person of the child may appoint a guardian
of the child, for a period of up to 60 days through the use of this form. #f the short!term guardian
is appointed by both li"ing parents of the child, the parents need not sign the form at the same
time.
$. %arent (or guardian) and &hild. #, ''''''''''''''''''''''''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
(insert name of appointing parent or guardian), currently residing at '''''''''''''''''''''''
''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
(insert address of appointing parent or guardian), am a parent (or the guardian of the person) of
the following child (or of a child li(ely to be born):
Birthdate
)ame or epected birthdate
''''''''''''''''''''''''''''''''' '''''''''''''''''''''''''''''''''''''''
(insert name and date o !irt" o #"i$d% or insert t"e &ords 'not (et !orn) to a**oint a
s"ort-term +,ardian or a #"i$d $i-e$( to !e !orn and t"e #"i$d.s e/*e#ted date o !irt"01
*. +uardian. # hereby appoint the following person as the short!term guardian for the child:
)ame: ''''''''''''''''''''''''''
Address: ''''''''''''''''''''''''''
''''''''''''''''''''''''''
''''''''''''''''''''''''''
(insert name and address o a**ointed *erson0
,. -ffecti"e .ate. This appointment becomes effecti"e: (chec( one if you wish it to be
applicable):
( ) /n the date that # state in writing that # am no longer either willing or able to ma(e and
carry out day!to!day child care decisions concerning the child.
( ) /n the date that a physician familiar with my condition certifies in writing that # am no
longer willing or able to ma(e and carry out day!to!day child care decisions concerning the child.
( ) /n the date that # am admitted as an in!patient to a hospital or other health care
institution.
( ) /n the following date: '''''''''''''''''''''''''' (insert date).
( ) /ther: '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' (insert other).
2NOTE3 I t"is item is not #om*$eted% t"e a**ointment is ee#ti4e immediate$( ,*on t"e
date t"e orm is si+ned and dated !e$o&15
0. Termination. This appointment shall terminate 60 days after the effecti"e date, unless it
terminates sooner as determined by the e"ent or date # ha"e indicated below: (chec( one if you
wish it to be applicable)
( ) /n the date that # state in writing that # am willing and able to ma(e and carry out day!
to!day child care decisions concerning the child.
( ) /n the date that a physician familiar with my condition certifies in writing that # am
willing and able to ma(e and carry out day!to!day child care decisions concerning the child.
( ) /n the date that # am discharged from the hospital or other health care institution
where # was admitted as an in!patient, which established the effecti"e date.
( ) /n the date which is '''''''''''' days after the effecti"e date. (1tate a number of
days, but no more than 60 days).
( ) /ther: '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' (insert other).
2NOTE3 I t"is item is not #om*$eted% t"e a**ointment &i$$ !e ee#ti4e or a *eriod o 67
da(s% !e+innin+ on t"e ee#ti4e date15
2. .ate and signature of appointing parent or guardian. This appointment is made this
'''''''''''' (insert day) day of '''''''''''' (insert month and year).
1igned: ''''''''''''''''''''''''''''
(appointing parent or guardian)
6. 3itnesses. # saw the parent (or the guardian of the person of the child) sign this
instrument or # saw the parent (or the guardian of the person of the child) direct someone to sign
this instrument for the parent (or the guardian). Then # signed this instrument as a witness in the
presence of the parent (or the guardian). # am not appointed in this instrument to act as the short!
term guardian for the child.
3itness: '''''''''''''''''''''''''' (signature)
'''''''''''''''''''''''''' (print name)
'''''''''''''''''''''''''' (address)
''''''''''''''''''''''''''
3itness: '''''''''''''''''''''''''' (signature)
'''''''''''''''''''''''''' (print name)
'''''''''''''''''''''''''' (address)
''''''''''''''''''''''''''
4. Acceptance as short!term guardian. # accept this appointment as short!term guardian on
this '''''''''''' (insert day) day of '''''''''''' (insert month and year).
1igned: ''''''''''''''''''''''''''''
(short!term guardian)
5. &onsent of child6s other parent. #, ''''''''''''''''''''''''''''''''''''''''
(insert name of child6s other li"ing parent), currently residing at '''''''''''' (insert address of
child6s other li"ing parent), hereby consent to this appointment on this '''''''''''' (insert day)
day of '''''''''''' (insert month and year).
1igned: ''''''''''''''''''''''''''''
(consenting parent)