Power Of Attorney For Care Of A Minor Child
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5POWER OF ATTORNEY FOR CARE OF A MINOR CHILD
Use of this form is authorized by T.C.A. § 34-6-301 et seq. Completion of this form,
along with the proper signatures, is sufficient to authorize enrollment of a minor in school
and to authorize medical treatment. However, a school district may require additional
documentation/information as permitted by this section of Tennessee law before enrolling
a child in school or any extracurricular activities. Please print clearly.
Part I: To be filled out and/or initialed by parent(s).
1. Minor Child’s Name ________________________________________________
2. Mother/Legal Guardian’s Name & Address ______________________________
______________________________
______________________________
3. Father/Legal Guardian’s Name & Address ______________________________
______________________________
______________________________
4. Caregiver’s Name & Address
______________________________
______________________________
______________________________
(Please Initial)
5. (____) Both parents are living, have legal custody of the minor child and have
signed this document;
OR
(____) One parent is deceased;
OR
(____) One parent has legal custody of the minor child and both parents have
signed this document and consent to the appointment of the caregiver;
OR
(____) One parent has legal custody of the minor child, and has sent by Certified
Mail, Return Receipt requested, to the other parent at last known address,
a copy of this document and a notice of the provisions in § 34-6-305; or
the non-custodial parent has not consented to the appointment and consent
cannot be obtained because ______________________________.
6. Temporary care-giving authority regarding the minor child is being given to the
caregiver because of the following type of hardship (initial at least one):
(____) the serious illness or incarceration of a parent or legal guardian;
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