Power Of Attorney Form Delegating Parental Powers
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2POWER OF ATTORNEY DELEGATING PARENTAL POWERS
Principal, the parent or guardian of the children listed below, hereby appoints the below-named Agent/Attorney-in-Fact to
act in name and place of Principal, parent, or guardian to have parental authority and to perform general
responsibilities of a parent and execute any of the below-listed specific acts, EXCEPT for authorizing the marriage or
adoption of the minor children.
1.
INFORMATION NEEDED:
Current full legal name of the parent or guardian who is giving the temporary authority over the child(ren)?
•
The full legal name of each child
- and –
Date of birth for each child
•
1.
2.
3.
4.
5.
The full legal name of the person who agrees to and accepts the delegation of Parental Authority: (This is the
•
same as the Attorney-in-Fact mentioned above)
The full physical address of the person who agrees to and accepts the delegation of Parental
•
Authority:
RESPONSIBILITIES DELEGATED: Check ONE if you, as a parent or guardian agree to give the following powers
2.
to the Attorney-in-Fact:
I delegate all parental responsibilities I might perform myself
I delegate only the specific parental responsibilities named as follows:
DURATION: This delegation of Parental Powers lasts up to six (6) months unless I, as Principal, Parent or
3.
Guardian, revoke it earlier, or unless I am a member of the military on active duty. Check only one:
This Parental Power of Attorney begins on
and expires not more than six
(6) months later on
, unless I revoke it earlier or unless I am a member of
the military on active duty.
I am an active duty Military Member who is a parent or guardian of a minor child or ward. I delegate
Parental Powers to my Attorney-in-Fact for a period not to exceed one year beginning
on
, and expiring not more than twelve (12) months later on
, unless I revoke it earlier.
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