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Please be advised that the undersigned, parent(s) of ________________________________________
do temporarily grant guardianship rights and responsibilities to: ____________________________________________________________________________________
____________________________________________________________________________________
and guardianship is subject to revocation and/or order of the court.
| Parent's Signature: _____________________________ | NOTARY PUBLIC | |
| ____________________________________________ | ||
| Address:_____________________________________ | Stamp: | |
| ____________________________________________ | ||
| Phone: ______________________________________ | Date: _______________ |
| Guardian's Signature: __________________________ | NOTARY PUBLIC | |
| __________________________________________ | ||
| Address:____________________________________ | Stamp: | |
| ___________________________________________ | ||
| Phone: _____________________________________ | Date: _______________ |
| Superintendent's Signature: | NOTARY PUBLIC | |
| ___________________________________________ | ||
| Stamp: | ||
| Date: _______________ |