Power Of Attorney Information Form - New Mexico Page 2
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2POWER OF ATTORNEY for a minor child
I declare that I am the PARENT and/or LEGAL GUARDIAN,
PARENT NAME
BIRTH DATE
SOCIAL SECURITY #
CITY/STATE of RESIDENCE
of this minor CHILD,
CHILD NAME
BIRTH DATE
SOCIAL SECURITY #
CITY/STATE of RESIDENCE
Pursuant to 45-5-104 NMSA, do hereby appoint this CAREGIVER, my true and lawful attorney in
fact, to act in my name, place and stead, in the event that I am unavailable and a decision must be
made and/or authorization given for the above named child regarding medical treatment, education
matters, participation in religious or recreational activities or in any other matters involving my child.
I authorize the Caregiver in this event to take any and all steps, as fully and for all intents and
purposes as I might do or could do if personally present. I understand that pursuant to the statute this
power of attorney terminates six months from the date executed and I may renew it at that time.
CAREGIVER NAME
BIRTH DATE
SOCIAL SECURITY #
CITY/STATE of RESIDENCE
I declare under penalty or perjury under the laws of the state of New Mexico that
the foregoing is true and correct.
PARENT SIGNATURE
Print Parent Name
NOTARY PUBLIC ACKNOWLEDGMENT
(Photo Identification, Signature Witnessing & Notary Seal Required)
This affidavit was subscribed, sworn to and acknowledged before me this,
the ____________ day of the month of _______________________, 201_____.
NOTARY PUBLIC
My Commission Expires
(Seal)
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