The following is a suggested form that may be used by a person having parental authority to delegate the provisional custody of the named child: 

PROVISIONAL CUSTODY BY MANDATE 

STATE OF LOUISIANA 

PARISH OF ____________________ 

BE IT KNOWN THAT on this ____ day of __________, 20___, before me, the undersigned notary, and in the presence of the competent witnesses hereinafter named and undersigned: 

Personally came and appeared: 

(affiant’s name, marital status, and mailing address), who is the (person(s) having parental authority) of (child(ren)) and who, by these presents makes, names, constitutes, and appoints (mandatary’s name and mailing address) and grants provisional custody of each of the above named children, to provide for the health, education, and welfare of each 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 necessary for the health, safety, and welfare of each child. 

____ (2) Enroll each child in such schools or educational institutions as may be necessary for his proper education. 

____ (3) Discipline each child in such reasonable manner as may be necessary for his 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 each child. 

This Provisional Custody by Mandate will continue to be effective until _______________, 20___, or one year from date hereof, whichever period is shorter. 

I agree that any third party who receives a copy of this document may rely upon the authority granted the mandatary as indicated herein and may act in reliance on such authority. 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 mandatary does hereby accept the provisional custody of each child named herein. 

THUS DONE AND PASSED at ____________________, state of _______________, in the presence of the undersigned, competent witnesses, who sign these presents with the appearer(s) and me, notary, after due reading of the whole. 

WITNESSES: 

..................................................................................................................................................................................................................................

(Person having parental authority) 

..................................................................................................................................................................................................................................

(Other person having parental authority) 

.................................................................................................................

(Mandatary) 

___________________________________ 

NOTARY PUBLIC