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Washington Guardian of Minor Power of Attorney Form

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Washington Guardian of Minor Power of Attorney Form is a legal document developed so parent(s) or guardian(s) can place their child in the care of trusted friends or family when they are unavailable to care for their children due to illness or some long-term absence. It should be noted that all entities charged with the care of the child sign this document. Thus, if two parents have custody of a child then both parents must sign this form to approve the agent’s use of guardian powers over the child. The parents will always retain authority over the child and can decide how extensive the guardian powers are and/or upon a specific time period when they are active. If more space is needed for additional information, continue on an added sheet and attach to the document. This document may be revoked in writing at any time by the parent(s)/guardian(s). Such a revocation should be successfully delivered into the possession of the individual whose guardian powers are being revoked.

Laws – RCW 11.94.010(4)

For  Medical Emergencies Only – Only for the use, as described in RCW 11.94.010(4), for decision-making responsibility in a health care emergency on behalf of the minor.

How to Write

1 – A Guardian May Be Appointed With Principal Powers With This Form

Use any of the buttons captioning the preview picture of the Washington Template on this page. Once you have opened a copy, save it to your machine. You may enter information directly to the document using a compatible editing program or you may fill it out manually after printing a copy.

2 – Identify The Minor Whose Welfare Will Be Entrusted To The Intended Guardian

The first part of this delegation of Guardian Powers will discuss the Child who will be in the care of the intended Guardian. Locate the words “For The Minor Named,” then furnish the Child’s Full Name in the blank area immediately following them.  

The Child’s Date of Birth (as recorded on his or her Birth Certificate) should also be included in the description of this Minor. Use the blank space after the words “Born On The” to report the Calendar Day. Then use the two blank spaces after the phrase “Day Of” to record the Month and Year of the Child’s Birth Date

3 – Everyone Currently In Charge Of The Child’s Well Being Must Be Defined

The next portion of this document will require some input regarding the current Caretaker of the Child. If the Child has two Parents, both must be reported here. Use the empty space after the word “I” to report the Parent or Court Appointed Guardian’s First, Middle, and Last Name.

Define the role of this individual by checking either the “Parent” checkbox or the “Court Appointed Guardian” checkbox (whichever is an appropriate description).  Lastly, using the blank space after the words “…A Street Address Of” to supply the Parent or Court Appointed Guardian’s Building Number, Street Name, and Unit Number in his or her Residential Address. The City and State of this Address should be supplied to the available areas after the phrases “City Of” and “State Of” (respectively).  

The next part of this section shall deal with the other Parent or Co-Guardian’s information. Use the statement below the label “(If Co-Guardian/Parent Exists)” to supply this entity’s Name, Role, and Residential Address. 

4 – The Intended Guardian Must Be Declared In This Appointment

Now we must take a moment to identify precisely who will have Guardian Powers over the Child named in the first part of this document. Locate the roman numeral “II” in the margin then, in the blank area just before the term “As My Attorney-in-Fact…,” enter the First, Middle, and Last Name of the intended Guardian.

Now, on the blank line placed before the label “(Relation),” fill in what role the intended Guardian plays in the Child’s life

The next item of information required by this paperwork is the intended Guardian’s Address of Residence. His or her Building Number, Street Name, and Unit Number should be reported in the next available area. The Address should be continued by entering its City and State on the next two lines.

5 – A Definition To The Level Of Authority Being Granted Must Be Provided

The nature of the intended Guardian’s Principal Powers will have to be adequately attached to this delegation. This can be documented easily through the Principal Act of Initialing. Locate the statement “I/We Delegate To The Attorney-in-Fact The Powers Of…” If the Parent/Court Appointed Guardian intends to allow the intended Guardian the use of his or her full Authority, then the Parent/Court Appointed Guardian should initial the blank line in the first choice an initial the checkbox. If a specific type of Authority is being appointed to the intended Guardian, then this Limited Authority should be identified clearly (i.e. the Principal Authority to arrange for the Child’s Health Care) on the blank lines supplied in the second choice. If there is not enough room here to fully report on this, you may cite an attachment and continue this part of the delegation on another sheet of paper.

6 – The Term Of The Guardian’s Principal Powers Will Need To Be Applied

In addition to the level of Power being granted over the Child/Minor, this template will require a definitive time period or lifespan of Effect for these Powers. In the fourth (IV)section, supply the exact Calendar Date when the intended Guardian will officially be allowed to and able to act as such on the blank spaces furnished in the first statement.  To round out this section, the Parent/Court Appointed Guardian will also have to define this document’s Termination Date. Three definitive statements, each preceded by a blank line and checkbox, have been supplied to obtain this definition easily. The Parent/Court Appointed Guardian can automatically Terminate these Powers as of a specific Date if the first statement (Choice A) has this Calendar Date supplied to it and it is initialed and checked by the Parent/Court Appointed Guardian. The remaining two Choices (A and B) allow the Parent/Court Appointed Guardian to declare either the Date he or she becomes incapacitated or the Date he or she dies as the Termination Date. If the Parent/Court Appointed Guardian prefers either of these Choices, then he or she must initial and check the blank line and checkbox of his or her choice.

7 – Every Parent/Court Appointed Guardian Identified Above Must Execute This By Signature

The Parent or Court Appointed Guardian of the Child will need to supply evidence that he or she intends to appoint the Guardian Powers defined here to the intended Guardian. To provide such proof, he or she must properly sign this paperwork. Three items are needed for this task. If there are two Parents or Court Appointed Guardians, enough room has been presented so that each will have a separate area to work with.

The first item to attend to is the blank line designated with the bold label “Parent/Court Appointed Guardian Signature.” The Parent or current Guardian of the Child must sign this line.

The next two items, labeled as “Print Name” and “Date,” and must have the Printed Name of the Signature Parent/Court Appointed Guardian along with the Current Date at the time of signing furnished upon them by the Signature Parent or Court Appointed Guardian. The next Signature area should only be satisfied by the second Parent or current Guardian. If there is no such entity, it may be left blank. The statement titled “Acceptance By Attorney-in-Fact” will need the attention of the intended Guardian listed in Article II. This individual must also supply evidence that he or she is aware of the Guardian Powers (and responsibilities) being bestowed here. This requirement can only be satisfied with the intended Guardian Action of reading then signing this statement. He or she must sign the “Attorney-in-Fact’s Signature” line then Print his or her Name and supply the Signature Date on the lines labeled “Print Name” and “Date.” The Witnesses present when the Parent(s)/Court Appointed Guardian(s) sign this document must also satisfy a requirement. Each one must attest to the validity of that signature in one of the “Affirmation By Witness” sections. Note the first blank space in each statement. Each of these statements must have the Name of a unique Witness printed on this line. Each Witness must produce his or her Signature, Printed Name, and Date on the blank lines below his or her statement The “Notary Acknowledgement” section will require attention from only one entity: the Notary Public present at the time of the Parent/Court Appointed Guardian Signing. He or she will notarize this paperwork when the concerned Signature Parties have satisfied the areas above.


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