© 2018 Nevada Supreme Court
Page 1 of 2 – Temporary Appointment of Guardian
(Child Guardianship)
SIX MONTH TEMPORARY GUARDIANSHIP UNDER A.B. 319, 2017 Leg., 79
th
Sess. (Nev. 2017)
I, (parent name) ,
of (address, city, state, zip code)
the parent of the minor child, (child’s name)
whose date of birth is , hereby desire to appoint
(guardian’s name)
of (address, city, state, zip code)
as short term guardian pursuant to A.B. 319, 2017 Leg., 79th Sess. (Nev. 2017).
1. I am the legal custodian of the minor child.
2. The other parent’s parental rights have not been terminated by court order.
3. The other parent’s whereabouts are known.
4. The other parent is willing and able to make and carry out daily child care decisions
concerning the minor child.
WARNING: If paragraphs 2, 3, and 4 have all been initialed, the other parent must sign page
2 of this form to make this short-term guardianship valid.
I specifically consent that the named guardian may make whatever decisions are
necessary concerning the day-to-day care of (child’s name) ,
including educational decisions, legal decisions and health decisions. The named guardian may
authorize all routine medical and dental care, and in the event of any medical emergency, the
named guardian may authorize operative care.
This guardianship shall expire six (6) months from the date that appears below
unless it is renewed by an acknowledged writing prior to the expiration date. This
guardianship may be terminated by me, by the guardian or by an order of a court of competent
jurisdiction that may appoint a guardian of the minor child, but such termination must be
accomplished by a written instrument.
I am the legal custodian of the minor child and am competent to make this appointment.
Date: ____________________ Parent’s Signature: ____________________________
Print Your Name: _____________________________
STATE OF _________________
COUNTY OF _______________
This instrument was acknowledged before me on
this ______ day of ________________, _______ by _______________________________
__________________________________
NOTARY PUBLIC
Carefully read each of the following statements and initial all that are true.
© 2018 Nevada Supreme Court
Page 2 of 2 – Temporary Appointment of Guardian
(Child Guardianship)
PARENT’S CONSENT
I hereby consent to the above-named person being appointed as my child’s guardian. I
declare under penalty of perjury under the law of the State of Nevada that the foregoing is true
and correct.
Date: ____________________ Parent’s Signature: _____________________________
Print Your Name: _____________________________
MINOR’S CONSENT
I hereby consent to the above-named person being appointed as my guardian.
Date: ____________________ Minor’s Signature:_____________________________
Print Your Name: _____________________________
GUARDIAN’S ACCEPTANCE OF APPOINTMENT
I, (guardian’s name) hereby accept
this appointment as temporary short term guardian for the minor child identified in this
instrument and will accept responsibility for the care, custody, and control of said minor child,
including all necessary authority and power to furnish and provide care and services to said
minor child as may seem necessary, proper, or desirable in the child’s best interest and welfare,
including, but not limited to, food, clothing, shelter, education, and medical-surgical-dental care
and treatment. I understand this guardianship shall become effective upon my execution of this
document in the presence of a Notary Public for a period of six (6) months and may be
terminated by an instrument in writing signed by either parent of the minor child if that parent
has not had their rights legally terminated by an order of a court of competent jurisdiction.
Date: ____________________ Guardian’s Signature: __________________________
Print Your Name: _____________________________
STATE OF _________________
COUNTY OF _______________
This instrument was acknowledged before me on
this ______ day of ________________, _______ by _______________________________
__________________________________
NOTARY PUBLIC
IMPORTANT: If the minor child is fourteen (14) years of age or older, the minor child
must sign below to consent to the temporary short term guardianship.
IMPORTANT: If items 2, 3, and 4 on the prior page were all initialed, the other parent
must sign below to consent to the temporary short term guardianship.