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APPOINTMENT OF SHORT-TERM GUARDIAN FOR MINOR CHILD(REN) AND

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Page 1 of 8
APPOINTMENT OF
SHORT-TERM GUARDIAN FOR MINOR CHILD(REN) AND
DURABLE HEALTHCARE POWER OF ATTORNEY
I/We, and
,
constituting the sole or all of the custodial parent(s) or court-appointed guardian(s) of the
child(ren) named below, and residing at
hereby appoint
(1) , residing at
, with
telephone number(s) and
having the following relationship(s) to me us the minor(s):
; and
(optional) (2) , residing at
, with
telephone number(s) and
having the following relationship(s) to me us the minor(s):
,
to serve as the short-term guardian(s) over, and health care agents for, the following minor child(ren) (If
more space is needed here or elsewhere, attach additional sheets):
Full name: DOB:
Full name: DOB:
Full name: DOB:
and will become effective (check one):
immediately;
on , , 201 ;
upon the deaths, incapacity, or absence of all parents/guardians listed above; or
the occurrence of the following triggering event(s):
,
Page 2 of 8
and will terminate upon the earlier to occur of (a) the revocation in writing of any parent/guardian, (b) as
required by applicable law, or (c) (check one):
60 days;
on the day of , , 201 ; or
the occurrence of the following triggering event(s):
..
Additionally it is my/our intention that, if a court-appointed guardian is required for the child(ren), this
document shall additionally serve as a nomination of the above listed short-term guardians under Probate
Code Section 1502 et seq., who I/we believe will act in the child(ren)’s best interest. If these nominations
are inconsistent with any will I/we have executed, it is my/our intention that these documents be read
together if possible and otherwise that this document control unless it has terminated prior to my/our
death. Until such legal guardianship is established, this short-term guardianship and power of attorney is
intended to be of the person of the child(ren) only, not of their estate(s). It is my/our express intention that
the child(ren) not be taken into government child protective custody or foster care, unless all other short-
term guardian(s) are exhausted and even then I prefer that other relatives assume custody of the child(ren)
unless this box is checked: .
It is my/our intention that this document also qualify as a caregiver authorization affidavit under Section
6550 et seq. of the California Family Code, unless I/we have also attached or simultaneously executed a
statutory Caregiver’s Authorization Affidavit, in which case that/those document(s) shall instead control
with regard to caregiver authorization issues and the documents shall be read together as a harmonious
whole wherever possible.
To the maximum extent permissible under applicable law, the short-term guardian(s) will have the same
authority as I/we would have with respect to the custody and care of the minor child(ren), except as I/we
have specified below, including the right to perform the following acts and make the following decisions,
unless I/we have crossed out and initialed the particular power or otherwise specifically excluded it in
writing in this document or allowing such a power would invalidate this document, in which case only the
offending provisions shall be deemed stricken and ineffective:
To make all emergency and non-emergency healthcare decisions and execute all related
documents including insurance and waiver claims and forms, including the right to approve or
decline medical, dental, eye care, or psychiatric treatment, diagnostic tests, hospitalization, health
care, and personal care, in any situation in which, as the result of illness, disease, absence, injury,
or death I/we are incapable of making or communicating a decision with regard to my/our
child(ren)’s medical or dental care, provided that such decisions are made following consultation
with one or more licensed physicians or other licensed medical practitioners. I/we further delegate
the power to our short-term guardian(s) to select, employ, and discharge health care personnel,
including dentists and eye care professionals, for our child(ren)’s benefit and to contract in my/our
name and on my/our behalf for all health care services, including emergency and non-emergency
medical, dental, vision, and psychiatric care services and related goods. The short-term guardian(s)
should refer to any Additional Information we have attached to this document or left with the
guardian(s).
To make all decisions, execute all documents, and grant permission regarding the child(ren)’s
education, including but not limited to school enrollment, school and extracurricular activities,
school trips, and school conferences.
To generally do and perform all matters and to execute all documents with respect
to the custody and care of the child(ren) named herein.
Page 3 of 8
To travel with the child(ren) without limitations unless stated below:
within a -mile radius of ;
within the city county/parish state lines of only; or
other (e.g., to/from the following places only):
.
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) (Pub. L. 104-191), 45
CFR §§ 160-162, I/we are the Personal Representative of the minor child(ren) named above, and I/we
appoint and designate the above named short-term guardian(s)/health care agents as their Personal
Representative(s) for all purposes as provided in HIPPA, with the following limits, special conditions, or
instructions: None or
. I/we further appoint the short-term guardian(s) named herein as
Authorized Recipients under HIPPA and the California Confidentiality of Medical Information Act (“CMIA”),
entitled to request, receive, and review any information concerning the child(ren)’s physical or mental
health, including all HIPPA and CMIA protected information and medical and hospital records from covered
healthcare providers and to execute any releases or consents and pay any fees in connection therewith.
It is my/our intention that the short-terms guardian(s) serve without bond or compensation other than
reimbursement of expenses incurred on the child(ren)’s behalf. I/we shall remain personally liable for the
payment of all healthcare and education related expenses for the child(ren) to the same extent as if I/we
had personally contracted for such services. No third party shall have any liability to me/us for reasonably
relying on this document in good faith. If I/we have named two or more short-term guardians above,
either may act in the absence of the other(s).
I/We have executed this appointment and power of attorney in front of a notary public. Those of the
child(ren) named above who are 14 years of age or older may optionally also sign below to indicate their
seconding of the nomination of court-appointed guardians.
CUSTODIAL PARENT(S)/GUARDIAN(S):
Sign: Sign:
Print Name: Print Name:
Date Signed: Date Signed:
(OPTIONAL) NOMINATION OF PERSONS ABOVE AS GUARDIANS BY MINORS 14+:
Sign: Sign:
Print Name: Print Name:
Date Signed: Date Signed:
CONSENT OF SHORT-TERM GUARDIANS:
I/We have read the foregoing and with full knowledge and awareness of the gravity of the duties
delegated and assumed hereunder, I/we agree to assume full responsibility and to make decisions
Page 4 of 8
necessary for the well being of the minor child(ren) named above who will be living with
me/us during the short-term guardianship period in accordance with the best interests of the child and
agree to surrender the child(ren) to the parent(s)/guardian(s) upon request at any time or as specified
herein.
Sign: Sign:
Print Name: Print Name:
Date Signed: Date Signed:
State of California )
County of )
On before me, , Notary Public, personally
appeared , who proved to me on the basis of satisfactory
evidence to be the person whose name is subscribed to the within instrument and acknowledged to
me that she executed the same in her authorized capacity, and that by her signature on the
instrument the person, or the entity upon behalf of which the person acted, executed the instrument.
I certify under PENALTY of PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
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Page 5 of 8
REVOCATION OF SHORT-TERM GUARDIANSHIP
I/We, hereby
revoke
the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare
Power of Attorney dated the day of , 201 ; or
any and all Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare
Power of Attorney forms
with regard to
all minor child(ren) listed therein, or
the following named minor child(ren) only:
previously executed by me/us, effective as of
immediately;
the day of , 201 ; or
the occurrence of the following event(s) or condition(s), which were not previously specified in
the Appointment of Short-Term Guardian for Minor Child(ren) and Durable Healthcare Power of
Attorney dated the day of , 201
CUSTODIAL PARENT(S)/GUARDIAN(S):
Sign: Sign:
Print Name: Print Name:
Date Signed: Date Signed:
After signing, provide copies of this Revocation to the short-term guardian(s) whose power are being
terminated and to any third parties known to be relying on the short-term guardian(s)’s powers immediately.
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Page 6 of 8
ADDITIONAL INFORMATION
Child: Nickname(s):
Date of birth / / and last Tetanus Booster / / for the above named child.
The following is a list of known allergies and allergies to medications of the above named child:
The above named child has the following known medical conditions or problems:
The above named child is currently prescribed the following prescriptions medications at the following frequencies
and other instructions:
Family Physician: Phone Number:
Names of Parents/Guardians:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Person Responsible for charges:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Other Person to notify if parent/guardian is unavailable:
Phone: (H) ; (W) ; (Other)
Insurance Company: Policy or Group Number:
Signature of Financial Guarantor (required if different from parent/guardian):
Date: Print and complete one sheet per child
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ADDITIONAL
INFORMATION
Child: Nickname(s):
Page 7 of 8
Date of birth / / and last Tetanus Booster / / for the above named child.
The following is a list of known allergies and allergies to medications of the above named child:
The above named child has the following known medical conditions or problems:
The above named child is currently prescribed the following prescriptions medications at the following frequencies
and other instructions:
Family Physician: Phone Number:
Names of Parents/Guardians:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Person Responsible for charges:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Other Person to notify if parent/guardian is unavailable:
Phone: (H) ; (W) ; (Other)
Insurance Company: Policy or Group Number:
Signature of Financial Guarantor (required if different from parent/guardian):
Date: Print and complete one sheet per child
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signature
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ADDITIONAL
INFORMATION
Child: Nickname(s):
Page 8 of 8
Date of birth / / and last Tetanus Booster / / for the above named child.
The following is a list of known allergies and allergies to medications of the above named child:
The above named child has the following known medical conditions or problems:
The above named child is currently prescribed the following prescriptions medications at the following frequencies
and other instructions:
Family Physician: Phone Number:
Names of Parents/Guardians:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Person Responsible for charges:
Address:
City/State/Zip:
Phone: (H) ; (W) ; (Other)
Other Person to notify if parent/guardian is unavailable:
Phone: (H) ; (W) ; (Other)
Insurance Company: Policy or Group Number:
Signature of Financial Guarantor (required if different from parent/guardian):
Date: Print and complete one sheet per child
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APPOINTMENT OF SHORT-TERM GUARDIAN FOR MINOR CHILD(REN) AND

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Completed 16 January 2021

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