IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT FOR BREVARD COUNTY, FLORIDA. CASE NO.: IN THE INTEREST OF: Bar Code Label / Minor Child(ren) AFFIDAVIT OF PARENTAL CONSENT TO TEMPORARY PARENTAL RESPONSIBILITY BY EXTENDED FAMILY PURSUANT TO CHAPTER 751, FLORIDA STATUTES STATE OF FLORIDA COUNTY OF BREVARD THE UNDERSIGNED, BEING DULY SWORN HEREBY STATES: 1. My name is . 2. My current address is . 3. I am the (___) Mother (___) Father of: CHILD(REN)’S NAME(S) DATE OF BIRTH ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. I hereby give my consent for __________________________________________________ to have temporary legal parental responsibility of my child. 5. I understand that this consent will be filed with the Circuit Court of the Eighteenth Judicial Circuit In and For Brevard County, Florida.. 6. I understand that at any time after the Court enters an Order awarding temporary legal parental responsibility of my child to , I may request that the Court terminate the Order and return legal parental responsibility to me if the Court finds that I am a fit parent. Law 1038 – Rev. 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF PARENTAL CONSENT TO TEMPORARY CUSTODY BY EXTENDED FAMILY PURSUANT TO CHAPTER 751, FLORIDA STATUTES Page 2 7. Case No:_____________________________ I understand that by giving this consent, the Court will authorize ___________________________ to take all necessary steps to care for my child(ren), including but not limited to the following: A. Authorize and consent to all reasonable and necessary medical and dental care, including nonemergency surgery and psychiatric care; B. Secure copies of the child(ren)’s records held by third parties that are necessary to the care of the child, including but not limited to: medical, dental, psychiatric records, birth certificates and educational records; C. Enroll the child(ren) in school and grant or withhold consent for the child(ren) to be tested or placed in special school programs, including exceptional education; D. Do all other things necessary for the care of the child(ren). 8. I have given this consent freely and voluntarily. Dated: Signature of Petitioner Printed Name: Address: City, State, Zip: Telephone Number: STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on by . NOTARY PUBLIC or DEPUTY CLERK Print, type, or stamp commissioned name of notary or clerk.] Personally known Produced identification Type of identification produced Law 1038 – Rev. 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF PARENTAL CONSENT TO TEMPORARY CUSTODY BY EXTENDED FAMILY PURSUANT TO CHAPTER 751, FLORIDA STATUTES Page 3 Case No:_____________________________ IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ Ν fill in all blanks] I, {full legal name and trade name of nonlawyer} , a nonlawyer, located at {street} , {city} , {state} , {phone} , helped {name} , who is the petitioner, fill out this form. Law 1038 – Rev. 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com