Estimada consultante:
Le transcribo a continuación el formato que Usted debe llenar para PERMITIR TEMPORALMENTE LA CUSTODIA DE SU HIJA. Se trata de un formato uniforme y de aplicación general en todos los Estados de la Unión Americana.
Copie y pegue este documento en un procesador WORD, y en el mismo complete todos los datos requeridos.
Una vez lleno el formato, Usted debe presentarlo al Consulado Americano en México más cercano a su domicilio o bien, en la Embajada de USA en la Ciudad de México, solicitando los servicios de alguno de sus funcionarios con registro y sello notarial a efecto de que, ante la presencia de dicho funcionario Usted firme nuevamente y se identifique plenamente.
Tambien le recomiendo informarse sobre la disponibilidad de este servicio vía telefónica antes de realizar cualquier viaje o traslado a las oficinas de algún Consulado.
Si tuviera alguna otra duda, póngase en contacto con su servidor al correo lic_velazquez(arroba)y a h o o . c o m ( Debe escribirlo con el signo de arroba, sin paréntesis y sin espacios) o bien a cualquiera de los teléfonos que aparecen en mi oficina virtual de este foro.
Saludos.
AUTHORIZATION FOR TEMPORARY GUARDIANSHIP OF MINOR
Child
Full Legal Name: ___________________________________________________________________
Date of Birth: _______________________ Age: ___________ Gender: ___________
Doctor’s Information
Doctor’s Name: ____________________________________________________________________
Doctor’s Address: __________________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________ Policy #: ______________________
Allergies to Medications: ____________________________________________________________
Allergies (Other): ___________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant medical information:
_________________________________________________________________________________
_________________________________________________________________________________
Dentist’s Information
Dentist’s Name: ____________________________________________________________________
Dentist’s Address: __________________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: _________________
Dentist’s Insurer/Health Plan: __________________________ Policy #: ______________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Parent #2:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Temporary Guardian(s):
Temporary Guardian #1:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Temporary Guardian #2:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Emergency Contact:
Name: ___________________________________________________________________________
Address: _________________________________________________________________________
Home phone: __________________________ Work phone: __________________________
Cell phone: ____________________________ Pager: _______________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
1. I hereby declare that I have legal custody of the above named child.
2. I hereby grant my full permission and consent for the temporary guardian to establish a place of residence for my child, and for my child to reside and travel with said temporary guardian.
3. I hereby grant the temporary guardian my full authorization to make all decisions related to my child’s educational, religious, and recreational activities and undertakings.
4. I hereby grant the temporary guardian my full authorization to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the temporary guardian to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
5. This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the ______day of ____________________, 20____.
6. For the duration that the temporary guardian cares for my child, the costs associated with my child’s maintenance, living expenses, medical, and dental expenses shall be allocated and paid as follows: ____________________________________________________________.
7. In the event that more than one legal guardian exists, the use of the singular shall incorporate the plural. In the event that more than one temporary guardian is named, the use of the singular shall incorporate the plural.
Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy, and validity of the forgoing statement.
Parent 1’s signature: ________________________________ Date: ____________________
Parent 2’s signature: ________________________________ Date: ____________________
CONSENT OF TEMPORARY GUARDIAN
I hereby acknowledge the terms set forth above and agree to assume responsibility in accordance with those terms.
Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy, and validity of the forgoing statement.
Temporary Guardian 1’s signature: ________________________________ Date: ____________________
Temporary Guardian 2’s signature: ________________________________ Date: ____________________
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF __________________
COUNTY OF ________________
This document was acknowledged before me on ______________________ [date] by ________________________________________________ [name of principal].
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[Notary Seal, if any]:
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_______________________________
(Signature of Notarial Officer)
Notary Public for the State of ______________
My commission expires: __________________
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