SIX MONTH TEMPORARY GUARDIANSHIP UNDER A.B. 319, 2017 Leg., 79th Sess. (Nev. 2017) I, (parent name) , of (address, city, state, zip code) the parent of the minor child, (child222s name) whose date of birth is , hereby desire to appoint (guardian222s name) of (address, city, state, zip code) as short term guardian pursuant to A.B. 319, 2017 Leg., 79th Sess. (Nev. 2017). 1. I am the legal custodian of the minor child. 2. The other parent222s parental rights have not been terminated by court order. 3. The other parent222s whereabouts are known. 4. The other parent is willing and able to make and carry out daily child care decisions concerning the minor child. WARNING: If paragraphs 2, 3, and 4 have all been initialed, the other parent must sign page 2 of this form to make this short-term guardianship valid. I specifically consent that the named guardian may make whatever decisions are necessary concerning the day-to-day care of (child222s name) , including educational decisions, legal decisions and health decisions. The named guardian may authorize all routine medical and dental care, and in the event of any medical emergency, the named guardian may authorize operative care. This guardianship shall expire six (6) months from the date that appears below unless it is renewed by an acknowledged writing prior to the expiration date. This guardianship may be terminated by me, by the guardian or by an order of a court of competent jurisdiction that may appoint a guardian of the minor child, but such termination must be accomplished by a written instrument. I am the legal custodian of the minor child and am competent to make this appointment. Date: Parent222s Signature: Print Your Name: STATE OF COUNTY OF This instrument was acknowledged before me on this day of , by NOTARY PUBLIC Carefully read each of the following statements and initial all that are true. American LegalNet, Inc. www.FormsWorkFlow.com PARENT222S CONSENT I hereby consent to the above-named person being appointed as my child222s guardian. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. Date: Parent222s Signature: Print Your Name: MINOR222S CONSENT I hereby consent to the above-named person being appointed as my guardian. Date: Minor222s Signature: Print Your Name: GUARDIAN222S ACCEPTANCE OF APPOINTMENT I, (guardian222s name) hereby accept this appointment as temporary short term guardian for the minor child identified in this instrument and will accept responsibility for the care, custody, and control of said minor child, including all necessary authority and power to furnish and provide care and services to said minor child as may seem necessary, proper, or desirable in the child222s best interest and welfare, including, but not limited to, food, clothing, shelter, education, and medical-surgical-dental care and treatment. I understand this guardianship shall become effective upon my execution of this document in the presence of a Notary Public for a period of six (6) months and may be terminated by an instrument in writing signed by either parent of the minor child if that parent has not had their rights legally terminated by an order of a court of competent jurisdiction. Date: Guardian222s Signature: Print Your Name: STATE OF COUNTY OF This instrument was acknowledged before me on this day of , by NOTARY PUBLIC IMPORTANT: If the minor child is fourteen (14) years of age or older, the minor child must sign below to consent to the temporary short term guardianship. IMPORTANT: If items 2, 3, and 4 on the prior page were all initialed, the other parent must sign below to consent to the temporary short term guardianship. American LegalNet, Inc. www.FormsWorkFlow.com