IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT IN AND FOR _________________COUNTY, FLORIDA IN THE INTEREST OF: DOB: Minor Child CASE NO. ______________ DOB: Minor Child PARENTAL CONSENT TO AWARD TEMPORARY LEGAL CUSTODY The undersigned being duly sworn, hereby states the following: 1. My name is _________________________________________________________________. 2. I am the ( ) mother ( )father of the above-named child(ren). 3. I acknowledge receipt of a copy of the Petition for Temporary Legal Custody in this action and hereby waive formal service of process and accepts service of process to the same degree as if said petition and a summons had been served by Sheriff or other certified process server duly authorized by law and consents to the jurisdiction of this Court. 4. My current address is _________________________________________________________ _____________________________________________________________________________. 5. I agree with the petition and hereby give my consent to ______________________________ __________________________________ to have temporary legal custody of my child(ren). 6. I understand that this consent will be filed with the court record in Okaloosa County, Florida. 7. I understand that at any time after the Court enters an order awarding temporary legal custody of my child(ren) I may petition to terminate or modify the order. 8. I understand that by giving this consent, the Court will authorize ______________________ _______________________________________________________ to take all the necessary steps to care for my child(ren), including but not limited to the following: American LegalNet, Inc. www.FormsWorkFlow.com a. Authorize and consent to all necessary and reasonable medical and dental care, including non-emergency surgery and psychiatric care; b. Secure copies of the child(ren)'s records held by third parties that are necessary for the care of the child(ren), including but not limited to, medical, dental and psychiatric records, birth certificates and other records, 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; and d. Do all others things necessary for the care of the child(ren). 9. I waive any further notice of this temporary legal custody proceeding and waive appearance at any hearing. I requests that a copy of the Order Granting Temporary Legal Custody be forwarded to me at the address listed above. _______________________________________________ Parent Signature STATE OF ______________________ COUNTY OF Sworn to or affirmed and signed before me on {date} ________________________by {name of parent} ______________________________________. _______________________________________________ NOTARY PUBLIC _______________________________________________ [Print, type, or stamp commissioned name of notary ] Personally known Produced identification Type of identification produced . American LegalNet, Inc. www.FormsWorkFlow.com