Petition for temporary guardianship without consent of parent
I,....................................................... (Insert name, address and telephone number of family member petitioning for temporary guardianship and relationship to minor), hereby declare my intent to be appointed temporary guardian of................................................ (Insert name(s), address(es) and telephone number(s) of minor(s) for whom the appointment of temporary guardian is being sought) as a result of emergency medical intervention resulting from abuse of drugs or alcohol by.......................................... (Insert name, address and telephone number), father/mother to...................................... (Insert name(s) of minor(s)), on........................... (Insert approximate date of the event).
I have notified the child(ren)'s other parent,.............................................................. (Insert name, address and telephone number), of my intent to petition this court for temporary guardianship.
I understand that filing this petition does not revoke the parental rights of the minor's parent(s) nor does it grant me any parental rights.
I understand that my rights and responsibilities as a temporary guardian toward the minor child(ren) named above will become effective upon the completion of a hearing and rendering of a decision by the court.
I understand that filing fees and other costs associated with these proceedings may be waived if i demonstrate the fees and other costs would constitute a financial burden to me and my family.
I hereby swear or affirm that the information contained herein is true and correct to the best of my knowledge.
.......................................................
(Date) (Signature of petitioner)
23 Pa.C.S. § 5622