Grandparent Power Of Attorney Form (Page 2 of 2) in pdf

(3) This power of attorney for the care of a minor child is being executed because of the following hardship (initial all that apply):

(A) The death, serious illness, or terminal illness of a parent;

(B) The physical or mental condition of the parent or the child such that proper care and supervision of the child

cannot be provided by the parent;

(D) The incarceration of a parent; or

(E) A period of active military duty of a parent.

(4) (Optional) If a guardian of my minor child is to be appointed, I nominate the following person to serve as such guardian:

__________________________________ (insert name and address of person nominated to be guardian of the minor child).

(5) I am fully informed as to all of the contents of this form and I understand the full import of this grant of powers to the agent

grandparent.

(6) I certify that the minor child is not emancipated, and, if the minor child becomes emancipated, this power of attorney shall no

longer be valid.

(7) Except as may be permitted by the federal No Child Left Behind Act, 20 U.S.C.A. Section 6301, et seq. and Section 7801, et

seq., I hereby certify that this power of attorney is not executed for the primary purpose of unlawfully enrolling the child in a

school so that the child may participate in the academic or interscholastic athletic programs provided by that school.

(8) I certify that, to my knowledge, the minor child’s welfare is not the subject of an investigation by the Department of Human

Resources

(9) I declare under penalty of perjury under the laws of the State of Georgia that the foregoing is true and correct.

Parent Signature:

Printed name:

Date:

Sworn to and Subscribed before me

this ______day of________________________20_____

this _________day of_________________________20_____

________________________________________________

_________________________________________________

Notary Public

My Commission Expires:_______________________

ADDITIONAL INFORMATION:

To the grandparent designated as attorney in fact:

(1) If a change in circumstances results in the child not living with you for more than six weeks during a school term and such change is not due

to hospitalization, vacation, study abroad, or some reason otherwise acceptable to the school, you should notify in writing the school in which you

have enrolled the child and to which you have given this power of attorney form.

(2) You have the authority to act on behalf of the minor child until each parent who executed the power of attorney for the care of the minor child

revokes the power of attorney in writing and provides notice of revocation to you as provided in O.C.G.A. Section 19-9-128.

(3) If you are made aware of the death of the parent who executed the power of attorney, you must notify the surviving parent as soon as

practicable. With the consent of the surviving parent, or if the whereabouts of the surviving parent are unknown, the power of attorney may

continue for up to six months so that the child may receive consistent care until more permanent custody arrangements are made.

(4) You may resign as agent by notifying each parent in writing by certified mail or statutory overnight delivery, return receipt requested, and if

you become unable to care for the child, you shall cause such resignation to be communicated to the parent. If communication with such parent is

not possible, you must notify child protective services or such government authority that is charged with assuring proper care of such minor child.

To school officials:

(1) Except as provided in the policies and regulations of the county school board and the federal No Child Left Behind Act, 20 U.S.C.A. Section

6301, et seq. and Section 7801, et seq., this power of attorney, properly completed and notarized, authorizes the agent grandparent named herein

to enroll the child named herein in school in the district in which the agent grandparent resides. That agent grandparent is authorized to provide

consent in all school related matters and to obtain from the school district educational and behavioral information about the child. Furthermore,

this power of attorney shall not prohibit the parent of the child from having access to all school records pertinent to the child.

(2) The school district may require such residency documentation as is customary in that school district.

(3) No school official who acts in good faith reliance on a power of attorney for the care of a minor child shall be subject to criminal or civil liability

or professional disciplinary action for such reliance.

DF-005

Page 2 of 2

06-30-08

Grandparent Power Of Attorney Form Page 2

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