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California Parental (Minor Children) Power of Attorney Form

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California Parental (Minor Children) Power of Attorney Form can be used by parents to authorize a trusted person to be the short-term guardian of their children and to make health care, educational and other decisions on behalf of their children on a temporary basis. This form is useful in the event that the parents are planning on going somewhere without their children and want to have someone they trust to make sure to be in charge and authorized to make decisions when they arise. This form also has a revocation section and a section where the parent can list any special needs or concerns involving each child.

LawsProbate Code § 1510-1517

How to Write

1 – Access The Correct File

You may download this form, “Appointment For Short Term Guardian For Minor Child(ren) And Durable Healthcare Power of Attorney,” by selecting the button labeled “PDF,” “ODT,” or “Word.” You may enter information onscreen to any of these with a form friendly browser, however, if you have a compatible software program (such as Adobe PDF or MS Word) you may also enter the information onscreen with such software. If you lack a form friendly browser or compatible software, then print the form and fill it in manually.

2 – Declaring The Parties

The first two blank lines of this document require the Full Names of each Parent who will grant Attorney-in-Fact or Guardian the responsibilities and powers of Principal Authority over their minor(s).

Use the checkbox to indicate whether the individual(s) currently in charge of the child (or minor) is a “parent(s)” or “court appointed-guardian(s)”

Once the current caretaker’s identity has been established, it is time to document the Address where he, she, or they live by entering the Building Number, Street Name, City, State, and Zip Code of Parent or current Guardian’s residence. 

It will be time to declare the identity of the Short-Term Guardian who shall be given Parental Principal Authority over the Child or Minor(s) in focus. Locate the term “…hereby appoint,” then enter the full Name of person who shall accept this responsibility and authority.

On the next blank line, record the Address where the Short-Term Guardian resides. This should be a complete Address of the physical location.

Report the Short-Term Guardian’s Phone Number

Locate the words “…having the following relationship(s),” indicate if the Short-Term Guardian being granted authority has a relationship with the Principal filling out this form, the Principals filling out this form, or to the minor by checking the box labeled “me,” “us,” or “the minor(s)” (respectively). Then, on the blank line that immediately follows this, record the nature of that relationship (i.e. uncle, grandparent, etc.).

The Parent or current Guardian may also declare an alternate Short-Term Guardian should the one previously listed be unable to fulfill his or her role. If this option will be enabled, then report this individual’s identity on the blank line following the term “(optional) (2).”

The next blank line must report the alternate Short-Term Guardian’s physical Address which must be followed by the alternate Short-Term Guardian’s Telephone Number(s)

The next required piece of information will be a definition to the relationship the alternate Short-Term Guardian has with either the Principal(s) or Minor(s). Use the check boxes to indicate if the alternate Short-Term Guardian has a relationship with one Principal (“me”), all Principals listed on this document (“us”), or the minor(s) (“minor(s)”). Then define this relationship on the next blank space.

Below this paragraph, there will be enough room to record the individual Name of each Minor this authority document will concern. On the blank space labeled Full Name, enter the Name of the child (minor) the Short-Term Guardian is being assigned responsibility and authority of. Then on the adjacent space, “DOB,” report the child or minor’s Date of Birth. There is enough room to record the identities of three minors, however, if there are more to report, you may continue the list on a separate sheet of paper then attach it.

3 – Declare The Active Period of Effect

It will be important to declare when precisely the power being granted to the Short-Term Guardian becomes active. You may define this Date below the statement “…and will become effective…” near the bottom of the page.

If this document goes into effect upon signing, mark the box labeled “immediately.”

If this document goes into effect on a specific Date, then mark the box that precedes the word “on” and enter the exact Date of Effect using the three blank spaces provided.

In some cases, this Document will go into effect only upon the absence, incapacity or death of the Parent(s) or current Guardians. If so, then mark the box preceding the words “upon the deaths…”

If the occurrence of certain circumstances will be the cause of this document going into effect, then mark the box preceding the words “the occurrence of the triggering…” and define the circumstances or conditions that will cause this document to go into effect.

This report on the Effective Period will continue at the top of the next page. Three choices will be available.

If the Expiration Date of the powers granted through this document is in 60 days, then mark the first box.

If the Authority Granted will terminate on a certain day, then mark the second box and enter the Date of Termination across the three spaces provided.

If an event or circumstance will trigger the termination of the Authority Granted in this document, then mark the third box and record the nature of catalyst that would cause this termination.

4 – Optional Custody

The paragraph starting with “Additionally it is my/our intention that…” should be read carefully. This paragraph will have a checkbox at the end of it. Check this box if a minor is faced with government housing/protective custody/etc. and the Principal wishes custody of the child to be with a Short-Term Guardian or Relative.

5 – Additional Criteria

The next page will begin with a definition required in events where travel is necessary. Locate the statement “To travel with the child(ren)…” Then define the manner in which the Short-Term Guardian may travel with the concerned child or minor(s) by selecting one of the three options provided.

If the Short-Term Guardian may only travel within a certain radius of an Address, then check the first box. This choice will also require the number of miles to be entered on the first blank space and the Address of the focal point after the words “…radius of”

If the Short-Term Guardian may only travel within a city, county/parish, or state then mark the second box. Here, you will need to indicate the area you are defining by checking the word “city,” “county/parish,” or “state lines.” On the blank space in this choice, fill in the Name of the County, City, or State the Short-Term Guardian is limited to.

If there is another criterion for travel, then mark the checkbox labeled “other” and use the blank lines to record the instructions or limitations the Short-Term Guardian must respect when traveling with the child or minor(s).

The next paragraph will assign the terms of the Health Insurance Portability and Accountability Act of 1996 to the Short-Term Guardian’s Authority. If this is to remain the case, then you may proceed to the next section. If there are any conditions or instructions to be applied, then mark the checkbox at the end of this paragraph and define these limitations or instructions on the blank line. There will be additional pages at the end of this form where you may input medical information.

6 – Required Notarized Signatures

The last area of this form will require the Signature of the Parent(s) or current Guardian(s). Below the heading “Custodial Parent(s)/Guardian(s),” there will be enough room for two Parent(s) or current Guardian(s) to provide his or her Signature, Printed Name, and Date of Signature. If there is only one Principal assigning power, fill in the items on the left side.

The heading “Nomination of Persons Above As Guardians By Minors 14+” is optional but will provide enough room for two individuals to submit a Nomination for the above Short-Term Guardians by providing their Signatures, Printed Names, and Date of Signatures

The next section, “Consent of Short-Term Guardians, requires each Short-Term Guardian named in this document to provide a Signature, Printed Name, and Date of Signature.

The final section of this form is provided for the exclusive use of the Notary Public handling this Signing. The Notarization of this form will complete its requirements. There will be a Revocation Form provided for future. Several additional sheets of paper have been provided so that you may supply additional information regarding the medical needs of the children this document is concerned with.


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