Because you are not always present with your children, you may need to delegate your parental
responsibility to someone in whose care you have entrusted your children. This will allow that
person to authorize necessary medical care and to have the right to discipline them when needed.
For this purpose, use a DELEGATION OF PARENTAL RESPONSIBILITY
SAMPLE DELEGATION OF PARENTAL RESPONSIBILITY
The undersigned, being the natural parent of __________________________________, a minor, hereby grants to
_________________________________, as Custodian, the following authority over said child:
1. To have custody of the child during the following periods:
2. To discipline said child in a reasonable manner as discussed previously.
3. To authorize any and all emergency medical treatment that is deemed necessary or advisable for any injury or illness
while child is in his/her custody.
Custodian agrees to use all reasonable means to protect the child while in his/her custody and to make reasonable
effort to reach the undersigned in the event of an emergency. Parent can be reached at:
Cell phone:____________________________________________________
Beeper: _______________________________________________________
Other phone:__________________________________________________
Other phone:__________________________________________________
_____________________________________
Parent
_____________________________________
Child’s Custodian
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