PROVISIONAL CUSTODY BY MANDATE

STATE OF LOUISIANA

PARISH OF                                  

      BE IT KNOWN THAT on this day of                                           , before me, the undersigned notary, and in the presence of the competent witnesses herein named and undersigned, personally came and appeared:

who resides at                                                                                                                        , parish of                                          , who is the mother/father [circle one] of the child-(ren) named herein (followed by date and place of birth):

who by these presents makes, names, constitutes and appoints                                                                                               , whose address is                                                                                                                                      , parish of                                                    , and who is related to the child(ren) as being their                                                                              , and grant provisional custody of the above-named child(ren), to provide for the health, education and welfare of the child(ren) as provided by the law on Provisional Custody by Mandate, specifically including the authority to:

• Consent to and authorize such medical care, treatment or surgery as may be deemed necessary for the health, safety and welfare of the child(ren). 
• Enroll the child(ren) in such schools or educational institutions as may be deemed necessary for their due and proper education.
• Discipline the child(ren) in such reasonable manner as may be necessary for their proper rearing, supervision and training.
• Do and perform all other acts as may be necessary for the shelter, support and general welfare of the child(ren).

     This Provisional Custody by Mandate will continue to be effective until                                                    or 1 year from the date thereof, whichever period is shorter.  I agree that any third party who receives a copy of the document may rely on the authority granted the agent as indicated herein and may act in reliance on such authority.  Revocation or termination by operation of law is not effective as to a third party until they have actual knowledge thereof.  I agree to indemnify and hold harmless any third party for any claims that arise against them because of reliance on this Provisional Custody by Mandate.  The undersigned agent does hereby accept the provisional custody of the child(ren) named herein.

 THUS DONE AND PASSED at                                                   , State of Louisiana, in the presence of                                                                                                                    and                                                                                                , competent witnesses, who sign these presents with the appearers and me, notary, after due reading of the whole.

WITNESSES:

MOTHER/FATHER:

GUARDIAN:

                                        NOTARY PUBLIC