Host Information Form Foreign Exchange Students Page 4
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5POWER OF ATTORNEY
Douglas County
FOREIGN EXCHANGE STUDENTS
School District RE-1
)
STATE OF ______________________
)
ss:
)
COUNTY OF ____________________
Pursuant to C.R.S. § 15-14-105 1973, I hereby delegate to
who resides at
whom I designate
my attorney in fact for this purpose, all of my power regarding custody, well being, and property of
, which are delegable under Colorado law, including the
power to consent to surgical operations and medical and dental treatment and to receive and deliver any
payment of money and property due the said minor child. In accordance with C.R.S. § 15-14-105, this
delegation does not include power to consent to marriage or adoption. This delegation is made for a
period not exceeding twelve (12) months, and shall terminate on _______________________ (determined
by a school official). This power of attorney shall not be affected by disability of the principal, and shall
remain in effect, to the extent permitted by C.R.S. § 15-14-105, not withstanding later disability or
incapacity of the principal at law, or later uncertainty as to whether the principal is dead or alive.
Date:
FEO Representative (printed name and signature)
FEO Address:
FEO City, State, Zip Code:
FEO Contact Email:
Subscribed and sworn to before me this ___________ day of _________________________, 20_____.
NOTARY PUBLIC
My commission expires: .
(NOTARY SEAL)
10/02/12
Page 3 of 4
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