Medical Durable Power Of Attorney For Health Care Form - State Of Colorado printable pdf download

Medical Durable Power of Attorney for Health Care

The undersigned, an adult of sound mind, executes this Medical Durable Power of Attorney ("power") pursuant to

sections 15-14-503 et seq., of the Colorado Revised Statutes, freely and voluntarily, with an understanding of its

purposes and consequences, and hereby grants to the adult leaders of St. Andrew United Methodist Church youth

program, designated as agents for this purpose, the power to authorize all medical, dental and hospital care for me and

the power to execute all documents and releases necessary to obtain such care, which powers shall not be impaired by

my disability, while participating in the St. Andrew UMC activity for which I am registered. I grant the forgoing

power for a period ending twelve months from day this Power of Attorney is signed. In consideration of my

participation in the activity for which I am registered, I, for myself and for my heirs, legal representatives and assigns,

covenant with St. Andrew UMC to never institute any suit or action at law or in equity against St. Andrew UMC, its

representatives, assigns, officers, staff or volunteers, for any sickness, injuries or death resulting from participation in

the activity. In executing this covenant, I expressly reserve any and all rights, causes of action, claims and demands

against any person, entity or association other than St. Andrew UMC, its representatives, officers, staff or volunteers. I

give permission for my image to be used in church-related print and web media.

Adult Participant______________________________________________

(18 and older)

Medical Insurance Company:________________________________________________

Name of Insured:____________________ Med Insurance Co. Phone________________

Group Name:_____________ Policy No._________________ Group No.____________

DATED this ________day of ________________, _________.

Signature __________________________________________

___________________________________ _______________ _________ ____________

Address

City

State

Zip

Home phone: ______________________ Business phone:_________________________

Emergency Contact Name: __________________________ Relationship: ___________

Emergency Contact Telephone Nos.: _________________________________________

STATE OF COLORADO, COUNTY OF___________________

The foregoing Medical Durable Power of Attorney for Health Care and covenant not to sue was subscribed and sworn

to before me this ______day of _____________, _______,

by________________________________________. Witness my hand and official seal.

My commission expires:_______________

SEAL

____________________________________

Notary Public

Adult POA pink card Oct 08 (4).doc

Medical Durable Power Of Attorney For Health Care Form - State Of Colorado