(f) The written instrument appointing a short-term guardian may, but need not, be in the following form: APPOINTMENT OF SHORT-TERM GUARDIAN
[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 365 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.
If you are a parent or guardian who is a member of the Armed Forces of the United States, including any reserve component thereof, or the commissioned corps of the National Oceanic and Atmospheric Administration or the Public Health Service of the United States Department of Health and Human Services detailed by proper authority for duty with the Armed Forces of the United States, or who is required to enter or serve in the active military service of the United States under a call or order of the President of the United States or to serve on State active duty, you may appoint a short-term guardian for your child for the period of your active duty service plus 30 days. When executing this form, include the date your active duty service is scheduled to begin in part 3 and the date your active duty service is scheduled to end in part 4.
This form may not be used to appoint a guardian if there is a guardian already appointed for the child, except 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 living 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 365 days through the use of this form. If the short-term guardian is appointed by both living parents of the child, the parents need not sign the form at the same time.]
1. Parent (or guardian) and Child. I, (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 likely to be born): (insert name and date of birth of child, or insert the words "not yet born" to appoint a short-term guardian for a child likely to be born and the child's expected date of birth).2. Guardian. I hereby appoint the following person as the short-term guardian for the child: (insert name and address of appointed person).3. Effective date. This appointment becomes effective: (check one if you wish it to be applicable)() On the date that I state in writing that I am no longer either willing or able to make and carry out day-to-day child care decisions concerning the child.() On the date that a physician familiar with my condition certifies in writing that I am no longer willing or able to make and carry out day-to-day child care decisions concerning the child.() On the date that I am admitted as an in-patient to a hospital or other health care institution.() On the following date: (insert date).() On the date my active duty service begins: (insert date).( ) Upon an administrative separation, as defined in Section 11-1.() Other: (insert other). [NOTE: If this item is not completed, the appointment is effective immediately upon the date the form is signed and dated below.]
4. Termination. This appointment shall terminate 365 days after the effective date, unless it terminates as determined by the event or date I have indicated below: (check one if you wish it to be applicable) () On the date that I state in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child, but not more than 365 days after the effective date.() On the date that a physician familiar with my condition certifies in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child, but not more than 365 days after the effective date.() On the date that I am discharged from the hospital or other health care institution where I was admitted as an in-patient, which established the effective date, but not more than 365 days after the effective date.() On the date which is (state a number of days, but no more than 365 days) days after the effective date.() On the date no more than 30 days after my active duty service is scheduled to end: (insert date active duty service is scheduled to end).( ) In the event the administrative separation, as defined in Section 11-1, has been resolved.() Other: (insert other). [NOTE: If this item is not completed, the appointment will be effective for a period of 365 days, beginning on the effective date.]
5. Date and signature of appointing parent or guardian. This appointment is made this (insert day) day of (insert month and year). Signed: (appointing parent)
6. Witnesses. I saw the parent (or the guardian of the person of the child) sign this instrument or I 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 I signed this instrument as a witness in the presence of the parent (or the guardian). I am not appointed in this instrument to act as the short-term guardian for the child. (Insert space for names, addresses, and signatures of 2 witnesses)7. Acceptance of short-term guardian. I accept this appointment as short-term guardian on this (insert day) day of (insert month and year). Signed: (short-term guardian)
8. Consent of child's other parent. I, (insert name of the child's other living parent), currently residing at (insert address of child's other living parent), hereby consent to this appointment on this (insert day) day of (insert month and year). Signed: (consenting parent)
[NOTE: The signature of a consenting parent is not necessary if one of the following applies: (i) the child's other parent has died; or (ii) the whereabouts of the child's other parent are not known; or (iii) the child's other parent is not willing or able to make and carry out day-to-day child care decisions concerning the child; or (iv) the child's parents were never married and no court has issued an order establishing parentage.]