Power Of Attorney For Minor Page 2

6. This Power of Attorney appointing [Legal Name] as my agent and attorney in fact

performing and acting for me in a parental capacity for my child [Legal Name of Child]

will be revoked automatically on the following date: ____/____/______.

7. It is not at all my intention to relinquish my full parental rights to the above mentioned

child.

Applicable Law

This contract shall be governed by the laws of the State of __________ in __________ County and

any applicable Federal Law.

__________________________________________________________

Date____________

Signature of Parent

By accepting this appointment and acting under it, I the attorney-in-fact (“Agent”) do hereby assume the

legal responsibilities of an agent.

_____________________________________________________________________Date____________

Signature of Attorney-in-Fact

WITNESS #1) _________________________________

WITNESS #2) _________________________________

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Parent category: Legal