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; 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 & Comptroller BY: ( ) Personally Known (SEAL) Deputy Clerk ( ) Produced Identification Type of I.D.__________________ OR ______________________________________ NOTARY PUBLIC - STATE OF FLORIDA (SEAL) American LegalNet, Inc. www.FormsWorkFlow.com