Power Of Attorney printable pdf download

Power of Attorney

Know all persons by these present that we (I), __________________________ and/or

(Parent Name)

_____________________________ of ________________________________ appoint

(Parent Name)

(Address)

_______________________ of __________________________ our attorney for us and

(Pastor or Team Leader)

(Address)

in our name and on our behalf to consent to the administration of whatever anesthetic and the performance of

such medical, dental, surgical treatment and/or operation as may be deemed necessary or advisable upon

_______________________________our minor child during the period of ____________ to ___________

(Youth Name)

and to execute all necessary instruments to carry out and perform any of aforesaid powers, and to do any

other acts requisite to carrying out such powers. I/we, the parent/parents, agree to be financially responsible

for the services provided. I/we authorize the release of medical information to or from my/our insurance

company and my/our personal physician.

IN WITNESS WHEREOF, I have hereunto executed this Power of Attorney on this

________ day of ____________________, _________.

(Month)

(Year)

Witnesses:

_____________________________

__________________________________

(Witness Signature)

(Parent Signature)

_____________________________

__________________________________

(Witness Signature)

(Parent Signature)

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Notarization of Power of Attorney Form

STATE OF _____________________ PARISH OR COUNTY OF _________________________________

On this _____day of ________________, ______ year, before me personally appeared

_________________________________________________to me known to be the same person described in

and who executed the within instrument, and who acknowledged the same to be the free act and deed thereof

Notary Public, _________________________________Parish or County _____________________________

State of ________________________

My Commission Expires ___________________________

Power Of Attorney