IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS APPOINTMENT OF SHORT-TERM GUARDIAN IT IS IMPORTANT TO READ THE FOLLOWING INSTRUCTIONS: By properly completing this form, a parent or the guardian of the person of the child is appointed a guardian of a child of the parent (or a minor ward of the guardian, as the case may be) for a period of up to 60 days. A separate form should be completed for each child. The person appointed as the guardian must sign the form, but need not do so at the same time as the parent or parents or guardian. This form may not be used to appoint a guardian if there is a guardian already appointed for the child, except that if a guardian of the person of the child has been appointed, that guardian may use this form to appoint a short-term guardian. Both living parents of a child may together appoint a guardian of the child, or the guardian of the person of the child may appoint a guardian of the child, for a period of up to 60 days through the use of this form. If the short-term guardian is appointed by both living parents of the child, the parents need not sign the form at the same time. 1. Parent (or guardian) and Children. I,___________________________________________________________, currently (Insert name of appointing parent or guardian) residing at________________________________________________, am a parent (or the guardian of the person) of the (Insert address of appointing parent or guardian) following child or children (or of a child likely to be born): Name Date of Birth (Or insert “not yet born” and enter the expected date of birth) __________________________________________________ ________________________________________________ __________________________________________________ ________________________________________________ __________________________________________________ ________________________________________________ __________________________________________________ ________________________________________________ 2. Guardian. I hereby appoint the following person as the short-term guardian for the child: __________________________________________________________________________________. (Insert name and address of appointed person) 3. Effective Date. This appointment becomes effective: (check one if you wish it to be applicable) ( ) On the date that I state in writing that I am no longer either willing or able to make and carry out day-to-day child care decisions concerning the child. ( ) On the date that a physician familiar with my condition certifies in writing that I am no longer willing or able to make and carry out day-to-day child care decisions concerning the child. ( ) On the date that I am admitted as an in-patient to a hospital or other health care institution. ( ) On the following date:_______________________________________________________ ( ) Other:_____________________________________________________________________ NOTE: If this item is not completed, the appointment is effective immediately upon the date the form is signed and dated below. 2002 © American LegalNet, Inc. 4. Termination. This appointment shall terminate 60 days after the effective date, unless it terminates sooner as event or date I have indicated below: (check one if you wish it to be applicable) determined by the ( ) On the date that I state in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child. ( ) On the date that a physician familiar with my condition certifies in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child. ( ) On the date that I am discharged from the hospital or other health care institution where I was admitted as an in-patient, which established the effective date. ( ) On the date which is _________________ (state a number of days, but no more than 60 days) days after the effective date. ( ) Other___________________________________________________________________________ NOTE: If this item is not completed, the appointment will be effective for a period of sixty days, beginning on the effective date. 5. Date and signature of appointing parent or guardian. This appointment is made this ____________ day of ___________________________, _________. Signed: ___________________________________ Appointing Parent 6. Witnesses. I saw the parent (or the guardian of the person of the child) sign this instrument or I saw the parent (or the guardian of the person of the child) direct someone to sign this instrument for the parent (or the guardian). Then I signed this instrument as a witness in the presence of the parent (or the guardian). I am not appointed in this instrument to act as the short-term guardian for the child. _______________________________________ _____________________________________ Witness Witness __________________________________________________ Address 7. _______________________________________________ Address Acceptance of short-term guardian. I accept this appointment as short-term guardian on this _____________ day of ____________________________, _____________. Signed:___________________________________________ Short-Term Guardian 8. Consent of child’s other parent. I___________________________________________________________ currently (Insert name of the child’s other living parent) residing at ______________________________________________________ hereby consent to this appointment on (Insert address of child’s other living parent) this____________day of_______________________, ___________. Signed:___________________________________ Consenting Parent NOTE: The signature of a consenting parent is not necessary if one of the following applies: (i) the child’s other parent has died; or (ii) the whereabouts of the child’s other parent are not known; or (iii) the child’s other parent is not willing or able to make and carry out day-to-day child care decisions concerning the child; or (iv) the child’s parents were never married and no court has issued an order establishing parentage. 2002 © American LegalNet, Inc.