Child Care Power Of Attorney Form - Hamilton County Juvenile Court (Page 3 of 10) in pdf

Hamilton County Juvenile Court

In Re:_________________________________

Case Number:_________________

Power Of Attorney

I, the undersigned, residing at

, in the county of

, state of

, hereby appoint the child's grandparent(s),

, residing at

, in the county of

, in the state of Ohio, with whom the

child of whom I am the parent, guardian, or custodian is residing, my attorney in fact to exercise any and all of

my rights and responsibilities regarding the care, physical custody, and control of the child,

, born

, having social security number (optional)

, except my authority to consent to marriage or adoption of the child

, and to

perform all acts necessary in the execution of the rights and responsibilities hereby granted, as fully as I might

do if personally present. The rights I am transferring under this power of attorney include the ability to enroll

the child in school, to obtain from the school district educational and behavioral information about the child, to

consent to all school-related matters regarding the child, and to consent to medical, psychological, or dental

treatment for the child. This transfer does not affect my rights in any future proceedings concerning the custody

of the child or the allocation of the parental rights and responsibilities for the care of the child and does not give

the attorney in fact legal custody of the child. This transfer does not terminate my right to have regular contact

with the child.

I hereby certify that I am transferring the rights and responsibilities designated in this power of attorney because

one of the following circumstances exists:

(1) I am: (a) Seriously ill, incarcerated or about to be incarcerated, (b) Temporarily unable to provide financial

support or parental guidance to the child, (c) Temporarily unable to provide adequate care and supervision of

the child because of my physical or mental condition, (d) Homeless or without a residence because the current

residence is destroyed or otherwise uninhabitable, or (e) In or about to enter a residential treatment program for

substance abuse;

(2) I am a parent of the child, the child's other parent is deceased, and I have authority to execute the power of

attorney; or

(3) I have a well-founded belief that the power of attorney is in the child's best interest.

I hereby certify that I am not transferring my rights and responsibilities regarding the child for the purpose of

enrolling the child in a school or school district so that the child may participate in the academic or

interscholastic athletic programs provided by that school or district.

I understand that this document does not authorize a child support enforcement agency to redirect child support

payments to the grandparent designated as attorney in fact. I further understand that to have an existing child

support order modified or a new child support order issued administrative or judicial proceedings must be

initiated.

Page 1 of 5

Form 1349

Child Care Power Of Attorney Form - Hamilton County Juvenile Court Page 3