The following form is used to grant temporary custody to another individual on a TEMPORARY basis.  It may be revoked at any time by the parent granting custody.  Before signing such a document granting any form of custody, a parent should consult an attorney.

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PROVISIONAL CUSTODY BY MANDATE

STATE OF LOUISIANA
PARISH OF _______________

BE IT KNOWN THAT on this ______ day of ___________, 200___, before me, the undersigned notary, and in the presence of the competent witnesses hereinafter named and undersigned:
Personally came and appeared:
 
___________________________, single, whose present mailing address is __________________________________________, who is the parent of ______________________________________, who, by these presents, make, name, constitute, and appoint ________________________, single, whose present mailing address ____________________________________________ and grant provisional custody of the above named child, to provide for the health, education, and welfare of the child as provided by the law on Provisional Custody by Mandate, specifically including the authority to:
INITIAL ALL APPLICABLE PROVISIONS:
______ (1) Consent to and authorize such medical care, treatment, or surgery as may be deemed necessary for the health, safety, and welfare of the child.
______ (2) Enroll the child in such schools or educational institutions as may be deemed necessary for her due and proper education.
______ (3) Discipline the child in such reasonable manner as may be necessary for her proper rearing, supervision, and training.
______ (4) Do and perform all other such acts as may be necessary for the shelter, support, and general welfare of the child.
This Provisional Custody by Mandate will continue to be effective until ________________________________.
I agree that any third party who receives a copy of this document may rely upon 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 he has actual knowledge thereof. I agree to indemnify and hold harmless the third party for any claims that arise against him because of reliance on this Provisional Custody by Mandate.
The undersigned agent does hereby accept the provisional custody of the child 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:

________________________ _________________________

________________________
 
________________________________
NOTARY PUBLIC