Power Of Attorney And Third-Party Custody Agreement printable pdf download

POWER OF ATTORNEY and THIRD-PARTY CUSTODY AGREEMENT

We, ________________________________________________

_, legal guardians of

___________________________________________, a minor child, in accordance with the provisions of

Indiana Code 29-3-9-1, do hereby and from the date of this instrument delegate and appoint Rachel Roth

Sawatzky and/or Jim Buller of Bethany Christian Schools [Name of representative], jointly and severally,

of [2904 South Main Street, Goshen], Indiana, as representative and attorney-in-fact (“Representative”)

for our minor child, with all necessary powers regarding his/her support, custody, and welfare.

Additionally, in accord with the provisions of Indiana Code §16-36-1, et seq., particularly IC §16-36-1-5,

6 and 7, we grant our Representative, the absolute right, power and authority, for either one of said

persons, to act and consent in all matters affecting the health and health care of our minor child, including

but not limited to the following acts: arrange for admission to and sign all admission documents and do all

things required in connection with his admission as an inpatient or outpatient at any hospital or health care

facility and to execute consents for medical treatment, procedures or surgery; and to execute releases of

liability or other waivers or releases as to any physician, surgeon, hospital and/or employees thereof, all as

our said representatives may in their discretion determine necessary or desirable, and with the same effect

as if we personally had so acted.

Our Representative may delegate the authority herein granted in accord with the provisions of

Indiana Code §16-36-1-6, but only during a period when they may not be reasonably available to exercise

the authority themselves. In the exercise of the authority granted to them by this appointment, our

Representative shall act in the best interests of our minor child consistent with the purposes expressed

herein, and they shall act in good faith.

This appointment shall be effective for a period of ________ (___) days [not to exceed 365] from

the date of this document unless we revoke the same by notifying our Representative orally or in writing.

IN WITNESS WHEREOF, we have signed this document this _____ day of ________________, 20

Notarized or Verified by:

___________________________________

Parent/Legal Guardian Contact Information:

Names: _______________________________________

Mailing Address: _______________________________________

_______________________________________

Emergency Telephone: _______________________________________

Email: _______________________________________

Power Of Attorney And Third-Party Custody Agreement