Form 51659 - Authorization To Make Medical Decisions For Minor (Page 2 of 2) in pdf

Authorization to Make Medical Decisions for Minor

1. AUTHORIZING PARTY (Parent/Guardian)

I, ___________________________________, residing at ______________________________________________

am: h the parent / h legal guardian / h legal custodian of the minor child(ren) listed below.

I do hereby authorize __________________________________________________________________, residing at

__________________________________, Phone #: ________________________ to exercise concurrently the rights

to agent and make healthcare decisions for the minor children whose names and dates of birth are:

_____________________________________________

____________________________________________

name and date of birth

_____________________________________________

____________________________________________

name and date of birth

The caregiver may NOT do the following: (If there are any specific acts you do not want the caregiver to perform, please

state those acts here.)

_____________________________________________________________________________________________

There are no court orders in effect that would prohibit me from exercising or conferring the rights and responsibilities

that I wish to confer upon this indivdual. I understand that, if the affidavit is amended or revoked, I must provide the

amended affidavit or revocation to all parties to whom I have provided this affidavit.

This document shall remain in effect until ____________ (not more than 60 days from today) or until I notify the

individual in writing that I have amended or revoked it.

I hereby affirm that the above statements are true, under pains and penalties of perjury.

Signature: ________________________________________________ Date: ___________________

Printed name: ________________________________________________

Telephone number: ________________________________________________

2. WITNESSES TO AUTHORIZING PARTY SIGNATURE

(To be signed by persons over the age of 18 who are not the designated caregiver.)

_____________________________________________

____________________________________________

Witness #1 Signature

Witness #2 Signature

Printed Name, Address and Telephone

_____________________________________________

____________________________________________

_____________________________________________

____________________________________________

_____________________________________________

____________________________________________

_____________________________________________

____________________________________________

FORM # 51659 (3/12) POD

Form 51659 - Authorization To Make Medical Decisions For Minor Page 2