IN THE CIRCUIT COURT IN THE EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA CASE NO.: 05 - - DR - - XXXX-XX IN THE INTEREST OF: CLOCK IN / 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 responsibility of my child. to have temporary legal parental 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 , I may request that the Court responsibility of my child to terminate the Order and return legal parental responsibility to me if the Court finds that I am a fit parent. 7. 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; Law 1038 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF PARENTAL CONSENT TO TEMPORARYCUSTODY BY EXTENDED FAMILY PURSUANT TO CHAPTER 751, FLORIDA STATUTES Page 2 Case No.: 05 - - DR - - XXXX-XX 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. Dated: Signature of Petitioner I have given this consent freely and voluntarily. Printed Name Address City, State, Zip Telephone Number: STATE OF FLORIDA COUNTY OF BREVARD Sworn to (or affirmed) and subscribed before me this by . day of , 20 , Signature of Notary Public-State of Florida Check one only: ___Personally known ___Produced I.D. Print, type or stamp Commissioned Name Type of I.D. produced__________________ IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ fill in all blanks] I, {full legal name and trade name of nonlawyer} a nonlawyer, located at {street} , {state} , , {phone} , helped {name} , {city} , who [ one only] _____petitioner or _____ respondent, fill out this form. Law 1038 ­ Rev. 05-20-2013 BAR CODE LABEL American LegalNet, Inc. www.FormsWorkFlow.com