La. Stat. tit. 9 § 954
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
La. R.S. § 9:954