Georgia Power Of Attorney For The Care Of A Minor Child Page 2

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(4) This power of attorney for the care of a minor child is being executed because of the following hardship (initial all that apply):

(A) The death, serious illness, or terminal illness of a parent;

(B) The physical or mental condition of the parent or the child such that proper supervision of the child cannot be

provided by the parent:

(D) The incarceration of a parent; or

(E) A period of active military duty of a parent.

(F) Other (Include Explanation):

(5) (Optional) If a guardian of my minor child is to be appointed, I nominate the following person to serve as such guardian:

(insert name and address of person nominated to be guardian of the minor child).

(6) I am fully informed as to all of the contents of this form and I understand the full import of this grant of powers to the agent

grandparent.

(7) I certify that the minor child is not emancipated, and, if the minor child becomes emancipated, this power of attorney shall no

longer be valid.

(8) Except as may be permitted by the federal No Child Left Behind Act, 20 U.S.C.A. Section 6301, et seq. And Section 7801, et

seq., I hereby certify that this power of attorney is not executed for the primary purpose of unlawfully enrolling the child in a

school so that the child may participate in the academic or interscholastic athletic programs provided by that school.

(9) I certify that, to my knowledge, the minor child’s welfare is not the subject of an investigation by the Department of Human

Resources.

(10) I declare under penalty of perjury under the laws of the State of Georgia that the foregoing is true and correct.

Signatures

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

Parent/Guardian Printed Name

Parent/Guardian Signature

Date

Notary

Subscribed and sworn before me on this

day of

, 201

NOTARY PUBLIC:

My commission expires:

Additional Information

To the grandparent designated as attorney in fact:

(1)

If a change in circumstances results in the child not living with you for more than six weeks during a school term and such change is not due to hospitalization,

vacation, study abroad, or some reason otherwise acceptable to the school, you should notify in writing the school in which you have enrolled the child and to

which you have given this power of attorney form.

(2)

You have the authority to act on behalf of the minor child until each parent who executed the power of attorney for the care of the minor child revokes the power

of attorney in writing and provides notice of revocation to you as provided in O.C.G.A. Section 19-9-128.

(3)

If you are made aware of the death of the parent who executed the power of attorney, you must notify the surviving parent as soon as practicable. With the

consent of the surviving parent, or if the whereabouts of the surviving parent are unknown, the power of attorney may continue for up to six months so that the

child may receive consistent care until more permanent custody arrangements are made.

(4)

You may resign as agent by notifying each parent in writing by certified mail or statutory overnight delivery, return receipt requested, and if you become unable

to care for the child, you shall cause such resignation to be communicated to the parent. If communication with such parent is not possible, you must notify

child protective services or such government authority that is charged with assuring proper care of such minor child.

To school officials:

(1)

Except as provided in the policies and regulations of the county school board and the federal No Child Left Behind Act, 20 U.S.C.A. Section 6301, et seq. and

Section 7801, et seq., this power of attorney, properly completed and notarized, authorizes the agent grandparent named herein to enroll the child named herein

in school in the district in which the agent grandparent resides. That agent grandparent is authorized to provide consent in all school related matters and to

obtain from the school district educational and behavioral information about the child. Furthermore, this power of attorney shall not prohibit the parent of the

child from having access to all school records pertinent to the child.

(2)

The school district may require such residency documentation as is customary in that school district.

(3)

No school official who acts in good faith reliance on a power of attorney for the care of a minor child shall be subject to criminal or civil liability or professional

disciplinary action for such reliance.

To health care providers:

(1)

No health care provider who acts in good faith reliance on a power of attorney for the care of a minor child shall be subject to criminal or civil liability or

professional disciplinary action for such reliance.

(2)

The parent continues to have the right to all medical, dental, and mental health records pertaining to the minor child.