Effective Date: ________ Name of Minor: _________________________ Date of Birth: _______
Termination Date: ________
Parent/Guardian: ___________________________________ Phone: (____)_____________________
Address: ___________________________________ City: ____________ State: ______ Zip: _______
Temporary Custodian: ________________________________ Phone: (____)____________________
Address: ___________________________________ City: ____________ State: ______ Zip: _______

1. Consent. Parents or guardians consent to the temporary custody of their minor child by custodianpursuant to the terms of this agreement.

2. Assumption of Risk. Parents or guardians realize that there is always a chance that minor child maybe injured while in the custody of custodian. In spite of this, parents and guardians assume the risk and exonerate custodian from liability for any accident, injury, or sickness occurring during the time custodian has custody of minor child except to the extent that such accident, injury or sickness resulted from the negligence or intentional misconduct of the temporary custodian.

3. Consent to Authorize Medical Care. Parents or guardians consent that custodian authorize on their behalf any first aid or medical care which custodian in his or her discretion deems necessary for the health or treatment of any illness or injury of minor child during this temporary custody.

_______________________         ________     ________________       _________

Signature of parent or legal guardian       Date             Signature of custodian      Date

_______________________        ________     _______________          _________

Signature of parent or legal guardian      Date              Signature of custodian      Date

STATE OF ARIZONA ACKNOWLEDGMENT
County of ________________
On this date, _________________, before me, the undersigned Notary Public, personally appeared ________________________, known to me or satisfactorily proven to be the person whose name is subscribed to this instrument and acknowledged that he/she executed the same. In witness whereof, I hereunto set my hand and official seal.

___________________ ______________________ _________________________

Notary Expiration            Notary Public                        Parent