Pennsylvania Consolidated & Unconsolidated Statutes
Chapter 56 - Standby and Temporary Guardianship
Section 5621 - Designation

(a) General rule.--Except as provided in subsection (b), a custodial parent may designate a temporary guardian by means of a written designation unless the minor has another parent or adoptive parent:
(1) whose parental rights have not been terminated or relinquished;
(2) whose whereabouts are known; and
(3) who is willing and able to make and carry out the day-to-day child-care decisions concerning the minor.
(b) Exception where other parent consents.--Notwithstanding subsection (a), a parent, legal custodian or legal guardian may designate a temporary guardian with the consent of the other parent.
(c) Contents.--
(1) A designation of a temporary guardianship shall identify the custodial parent, the minor or minors, any other parent, the temporary guardian and the triggering event or events upon which a named temporary guardian shall become a coguardian or guardian. The designation shall also include the signed consent of the temporary guardian and the signed consent of any other parent or an indication why the other parent's consent is not necessary.
(2) The designation shall be signed by the designating parent in the presence of two witnesses who are 18 years of age or older and not otherwise named in the designation, who shall also sign the designation.
(3) A parent may also but need not designate an alternate in the designation.
(4) A designation may but need not be in the following form:
‌
(Insert name of designator) do hereby appoint
‌
(Insert name, address and telephone number of temporary
guardian) as the temporary guardian of
‌
(Insert name(s) of minor(s) to take effect upon
‌ (Date).
I am the mother/father/other to‌
‌
(Insert name(s) of minor(s)).
‌
(Insert name(s) of other parent(s) of minor(s)) is the
father/mother/other of ‌
‌
(Insert name(s) of minor(s)).
By this designation, I am granting‌
(Insert name of temporary guardian) the authority to act for
90 days following the occurrence of‌
as a coguardian with me or as guardian of my minor
child(ren).
It is my intention to retain full parental rights to the extent consistent with my condition and to retain the authority to revoke the temporary guardianship if I so choose.
This designation is made after careful reflection, while I am of sound mind.
‌
‌
(Date)
(Designator's signature)
‌
‌
(Witness's signature)
(Witness's signature)
‌
‌
(Number and Street)
(Number and Street)
‌
‌
(City, State and Zip Code)
(City, State and Zip Code)
If applicable: I, ,

(Insert name of other parent)
hereby consent to this designation.
‌
‌
(Date)
(Signature of other parent)
‌
(Address of other parent)

I, ‌
(Insert name of temporary guardian), hereby accept my
nomination as temporary guardian of‌
‌
(Insert minor(s)'s name(s)). I understand that my rights and responsibilities toward the minor child(ren) named above will become effective upon(Date)
I further understand that in order to continue as temporary guardian for the child(ren), I must file a petition with the court of common pleas within 30 days of the order granting the petition for temporary guardianship.
‌
‌
(Date) (Signature of temporary guardian)
NOTARY SEAL

I hereby revoke the above temporary guardianship agreement.
‌(Parent signature)
‌(Date)
NOTARY SEAL