Authorization To Consent For Health Care Of Minor (Page 5 of 7) in pdf

Authorization To Consent For Health Care Of Minor Page 5

Part II: To be initialed by caregiver.

10. (____)

I understand that this document, properly executed, gives me the right to

enroll the minor child in the local education agency serving the area where

I reside.

11. (____)

I understand that this document does not provide me with legal custody.

12. (____)

I understand that, prior to enrollment, the local education agency may

require documentation of the minor child’s residence with a caregiver

and/or documentation or other verification of the validity of the stated

hardship.

13. (____)

I understand that, except where limited by federal law, I shall be assigned

the rights, duties, and responsibilities that would otherwise be assigned to

the parent, legal guardian or legal custodian pursuant to Tennessee Code

Annotated Title 49.

14. (____)

I understand that, if the minor child ceases to reside with me, I am

required by law to notify any person, school or health care provider to

whom I have given this document.

Part III: To be initialed by parent(s) and caregiver.

15. (____) (____)

We understand that, by accepting the power of attorney, if we

enroll a student in a school system while fraudulently representing

the child’s current residence or the parents’ hardship or

circumstances for using the power of attorney, either or both of us

is liable for restitution to the school district for an amount equal to

the per pupil expenditure for the district in which the student is

fraudulently enrolled. Restitution shall be cumulative for each year

the child has been fraudulently enrolled in the system and may

include costs and fees related to litigation.

________________________________________________________________________

I/We declare under penalty of perjury under the laws of the State of Tennessee that the

foregoing is true and correct.

STATE OF TENNESSEE)

COUNTY OF __________ )

______________________________ Date: ______________

Mother/Legal Guardian

The Mother/Legal Guardian, ______________________, personally appeared

Tennessee Power of Attorney for Minor Child

Authorization To Consent For Health Care Of Minor Page 5