TEMPORARY CHILD CARE

AUTHORIZATION FOR TEMPORARY CHILD CARE
This form must be printed and completed in ink.

I (we) the parents(s), ______________________________ and (or) _____________________________________

Father Mother

Residing at ________________________. _______________________. ______ __________ ________________

Street Address City St. Zip Code AC & Phone No.

Testify I (we) are the legal guardian(s) of the child listed below, a minor under the age of majority.

_______________________, ___________________________, _________________, ________ _____________

Name Address City St. Zip Code

DO HEREBY GRANT:

_______________________, ___________________________, _________________, ________ _____________

Name Address City St. Zip Code

A member of _____________________________________, located in ________________________, __________

Organization or Reenactment Unit City State

The authority to take temporary care of _________________________________________________, to take effect

Name of Child Listed Above

Beginning at ____________ o'clock on ______________, and ending at ___________ o'clock on _____________.

Time(AM/PM) Date Time(AM/PM) Date

The named child's pertinent medical history includes the following:

___/___/___ _____________________________________________ ___________________________________

Date of Birth Allergies and(or) Known Medical Conditions All Medications Currently or Recently Taken

______________________________ _______________________ _____________________________________

Name of Physician Physicians Phone Number Health Insurance Carrier

THE ABOVE NAMED CARETAKER(S) SHALL HAVE THE FOLLOWING AUTHORITY:
1. The power to authorize medical treatment or medical procedures in an emergency situation.

2. The power to make appropriate decisions regarding clothing, bodily nourishment, and shelter.

3. The power to make appropriate decisions about participation of the child in any aspect of the reenactment

event.

I (we), the legal guardians state the named child is physically and medically fit to participate in a WBTS re-enactment. Furthermore, I (we) agree to release the custodian, the named organization and the sponsors of the reenactment event of any and all liability for any injuries sustained by the named minor child, We also agree to pay any and all associated costs for medical treatment, including ambulance or transportation fees, doctor bills, hospital or emergency treatment facility fees and related medical needs expenses incurred by the child while under the care of the custodian.

I (we) agree to the content of, and will abide by the terms and conditions of this temporary assignation of custody.

(Signatures):

____________________________ ____________________________ __________________________________

Father Date Mother Date Temporary Custodian Date

Appeared before me, ___________________________ a notary public for the state of _______________, I affix my

hand and seal on this, the _____ day of _________, _______, My commission expires ____________.

____________________________(SEAL)

NOTARY