CHILD CARE AUTHORIZATION

We, the undersigned parents, John Smith and Jane Smith, of 123 Main Street, Townville, TN 54321, hereby grant Mike Johnson and Michelle Johnson, of 789 Central Avenue, Townville, Tennessee 54321, the authority to take temporary care of the following child(ren): Suzie Smith. This grant of temporary authority shall begin on 10/16/2012, and shall remain effective until terminated by both the undersigned. The above named Caretaker(s) shall have the power to: - seek appropriate medical treatment or attention on behalf of the child(ren) as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits - authorize medical treatment or medical procedures in an emergency situation - make appropriate decisions regarding clothing, bodily nourishment, and shelter - pick child(ren) up from school

Dated: 10/16/2012

________________________________________ John Smith

________________________________________ Jane Smith

John Smith Jane Smith 123 Main Street Townville, TN 54321 _______________ Jonathan Thompson Townville Elementary 456 Avenue D Townville, Tennessee 54321 Dear Jonathan Thompson: The purpose of this letter is to advise you of the authority given to Mike Johnson and Michelle Johnson while taking care of Suzie Smith. This grant of temporary authority shall begin on 10/16/2012 and shall remain effective until terminated by both of the undersigned. The above Caretaker(s) shall have the authority to: - seek appropriate medical treatment or attention on behalf of the child(ren) as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits - authorize medical treatment or medical procedures in an emergency situation - make appropriate decisions regarding clothing, bodily nourishment, and shelter - pick child(ren) up from school Please contact us at the above address if you have any questions or need additional information. Thank you for your cooperation in this matter. Sincerely,

John Smith

Jane Smith

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