......................................................
(Insert name of designator) do hereby appoint
......................................................
(Insert name, address and telephone number of temporary guardian) as the temporary guardian of
......................................................
(Insert name(s) of minor(s) to take effect upon
.................... (Date).
I am the mother/father/other to........................
......................................................
(Insert name(s) of minor(s)).
......................................................
(Insert name(s) of other parent(s) of minor(s)) is the father/mother/other of...............................
......................................................
(Insert name(s) of minor(s)).
By this designation, I am granting...................
(insert name of temporary guardian) the authority to act for 90 days following the occurrence of................... as a coguardian with me or as guardian of my minor child(ren).
It is my intention to retain full parental rights to the extent consistent with my condition and to retain the authority to revoke the temporary guardianship if I so choose.
This designation is made after careful reflection, while I am of sound mind.
........................................................
(Date) (Designator's signature)
........................................................
(Witness's signature) (Witness's signature)
........................................................
(Number and Street) (Number and Street)
........................................................
(City, State and Zip Code) (City, State and Zip Code)
If applicable: I,....................................... ,
(Insert name of other parent)
hereby consent to this designation.
........................................................
(Date) (Signature of other parent)
...........................................................
(Address of other parent)
I,........................................................
(Insert name of temporary guardian), hereby accept my nomination as temporary guardian of......................
..........................................................
(Insert minor(s)'s name(s)). I understand that my rights and responsibilities toward the minor child(ren) named above will become effective upon......................... (Date) I further understand that in order to continue as temporary guardian for the child(ren), I must file a petition with the court of common pleas within 30 days of the order granting the petition for temporary guardianship.
........................................................
(Date) (Signature of temporary guardian)
NOTARY SEAL
I hereby revoke the above temporary guardianship agreement.
.......................................... (Parent signature)
.............................. (Date)
NOTARY SEAL
23 Pa.C.S. § 5621