Power Of Attorney Form - Sole Legal Decision-Making Parent And Minor Child printable pdf download

POWER OF ATTORNEY

Re: Care, Custody, and Property of Minor Child

Sole Legal Decision-Making Parent

Minor Child

Name:____________________________________

Name:_____________________________________

Residence:

Medical Problems or Allergies:

_________________________________________

__________________________________________

_________________________________________

__________________________________________

Date of Birth: ______________________________

Date of Birth: _______________________________

Parent, as an adult who is the parent of Minor Child and is the sole legal decision-maker for Minor Child, hereby

constitutes and appoints Attorney-in-Fact to act in the name and place of Parent, and as the true and lawful attorney

for Parent as follows:

1. To consent to and authorize any emergency medical, surgical, or dental care, or any hospitalization which

Attorney-In-Fact deems necessary or advisable for the health or treatment of any illness or injury of Minor Child.

2. To consent to and authorize any educational services and make any education-related decisions that Attorney-

In-Fact deems necessary or advisable for the education and welfare of Minor Child.

This Power of Attorney shall not be affected by the disability or incompetence of the Parent and shall expire six

months after date of execution of this document by the Parent, unless terminated sooner. The Parent may revoke

this Power of Attorney by delivering written notice to Minor Child’s school.

I, the Parent, sign my name to this Power of Attorney this _______day of ____________________, ___________,

and, being first duly sworn, do declare to the undersigned authority, that I execute it as my free and voluntary act for

the purposes expressed in the Power of Attorney, and that I am eighteen years of age or older, of sound mind, and

under no constraint or undue influence.

_______________________________________

Signature of Parent

SUBSCRIBED AND SWORN or affirmed and acknowledged before me on:

My Commission Expires:

Notary Public

ACCEPTANCE OF APPOINTMENT

I accept my appointment as Attorney-In-Fact of the Minor Child.

_______________________________________

Date: ____________________________________

Attorney-In-Fact

Printed Name: ___________________________

Telephone: _______________________________

Residence: _____________________________

Other Contact Information:

_______________________________________

_________________________________________

Revised July 1, 2014

Power Of Attorney Form - Sole Legal Decision-Making Parent And Minor Child

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