IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT IN AN FOR ESCAMBIA COUNTY, FLORIDA IN THE INTEREST OF: Case NO.:________________________ Child's Name:_________________________ Division: ________________________ DOB:_________________________________ PARENTAL CONSENT AND WAIVER OF HEARING FOR TEMPORARY LEGAL CUSTODY The undersigned, being duly sworn, hereby state: 1. My name is _______________________________________________________. 2. My current address is___________________________________________________________________________ . 3. I am the ( ) mother ( ) father of the above-named child. 4. I hereby give my consent for ___________________________ to have temporary legal custody of my child. 5. I understand this consent may be filed with the court record in_____________________ County, Florida. 6. I understand that at any time after the Court enters an order awarding temporary legal custody of my child to _________________________________________, I may request the Court terminate the order and return legal custody to me. 7. I understand by giving this consent, the Court will authorize_______________________ take all necessary steps to care for my child, including but not limited to the following: a. Authorize and consent to all reasonable and necessary medical and dental care, including non-emergency surgery and psychiatric care; b. Secure copies of the child’s records held by third parties that are necessary to the care of the child, including but not limited to, medical, dental and psychiatric records, birth certificates and educational records; c. Enroll the child in school and grant or withhold consent for the child to be tested or placed in special school programs, including exceptional education; Consent and Waiver for Temporary Legal Custody.wpd American LegalNet, Inc. www.FormsWorkflow.com d. Do all other things necessary for the care of the child. 8. I waive Notice of Hearing as well as all future notices in connection with the Petition for Temporary Legal Custody, as filed. In so doing, I understand that I am also waiving my right to appear and be heard at the final hearing. _____________________________________ Parent's Signature ___________________________________ Parent’s Name Typed or Printed STATE OF FLORIDA COUNTY OF ESCAMBIA SWORN TO AND SUBSCRIBED before me this ___ day of ___________________________, 20_____. ERNIE LEE MAGAHA Clerk of the Circuit Court BY: ( ) Personally Known (SEAL) Deputy Clerk ( ) Produced Identification Type of I.D.__________________ OR ______________________________________ NOTARY PUBLIC - STATE OF FLORIDA (SEAL) Consent and Waiver for Temporary Legal Custody.wpd Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com