Authorization To Consent For Health Care Of Minor (Page 4 of 7) in pdf

Authorization To Consent For Health Care Of Minor Page 4

Temporary care-giving authority regarding the minor child is being given to the

caregiver ONLY upon the occurrence of (check at least one):

(____)

a serious illness or incarceration of a parent or legal guardian;

(____)

the detention or removal or deportation of a parent or legal guardian;

(____)

the loss or uninhabitability of the child’s home as a result of a natural

disaster;

(____)

the need for medical or mental health treatment (including substance abuse

treatment) by the parent or legal guardian;

(____)

or a physical or mental condition of the parent or legal guardian or the

child is such that care and supervision of the child cannot be provided;

(____)

other (please describe) _________________________________________

___________________________________________________________.

I/We the undersigned, authorize the named caregiver to do one or more of

the following:

(_____)

enroll the child in school and extracurricular activities (including

but not limited to Boy Scouts, Boys & Girls Club),

(_____)

obtain medical, dental, and mental health treatment for the child,

and

(_____)

provide for the child’s food, lodging, housing, recreation and

travel.

(_____)

I/We grant the following additional power to the named caregiver:

______________________________________________________

______________________________________________________.

8. (____)

I/We understand that this document does not provide legal custody to the

caregiver. If at any time I/we disagree with a decision of the named

caregiver or choose to make any healthcare or educational decisions for

my/our child, I/we must revoke the power of attorney, in writing, and

provide written documentation to the health care provider and the local

education agency (i.e., school).

9. (____)

I/We understand that this document may be terminated in another

written document signed by either parent with legal custody or by any

order of a court with competent jurisdiction.

Tennessee Power of Attorney for Minor Child

Authorization To Consent For Health Care Of Minor Page 4

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