Limited Power Of Attorney For Health Care Form - Kentucky County Of Kenton printable pdf download

Must be Notarized

Form E

LIMITED POWER OF ATTORNEY FOR HEATH CARE

That I, ________________________________, a resident of _________________ County,

________________, as parent and/or legal guardian of ____________________ (hereinafter “my

minor child”), do hereby make, constitute and appoint

and

_______________________________of _________________County, Kentucky, as my true

(youth minister)

true and lawful attorney in fact (hereinafter “my attorney”), for myself and my minor child and in

my name, place and stead, in my attorney’s sole discretion, to make any and all health care

decisions relating to my minor child while in the custody of my attorney. I give permission to my

attorney to make decisions relating to any necessary medical treatment including but not limited

to hospitalization, surgery, administration of medications, anesthesia or injections, for my minor

child while in the custody of my attorney.

This instrument is intended to, and does hereby, grant to my attorney full power and

authority to do and perform each and every act and thing whatsoever requisite, necessary, and

proper to be done, in the exercise of any of the rights and powers herein granted as fully, to all

intents and purposes, as I might or could do if personally present, and I hereby ratify and confirm

all that my attorney shall do or cause to be done by virtue thereof.

I, on behalf of myself, my minor child and our heirs, assigns, executors and personal

representatives, release, hold harmless and discharge forever my attorney, and his/her heirs,

assigns, executors and personal representatives for any and all liability, claims, losses, damages,

costs or expenses and waive any such claims arising directly or indirectly from health care

decisions made by my attorney pursuant to this power of attorney.

I, on behalf of myself and my minor child, agree to be financially responsible for any and

all health care treatment arising in connection with any illness or injury of my minor child and the

costs thereof and I agree to compensate my attorney for any such costs.

The rights, powers and authority of my attorney shall commence on

Nov. 16, 2017

and shall remain in full force and effect through Nov.19, 2017

unless this power of attorney is

revoked prior to that time.

IN TESTIMONY WHEREOF, witness my signature:

Printed name: _____________________________________________

Signature: ______________________________________

Date: _____________________

STATE OF KENTUCKY

COUNTY OF KENTON

Subscribed, sworn to and acknowledged before me this _____ day of _______________, 20__.

My Commission Expires: _________________________Notary Public ____________________

Limited Power Of Attorney For Health Care Form - Kentucky County Of Kenton