Appointment Of Short-Term Guardian For Minor Child(Ren) And Durable Healthcare Power Of Attorney

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APPOINTMENT OF
SHORT-TERM GUARDIAN FOR MINOR CHILD(REN) AND
DURABLE HEALTHCARE POWER OF ATTORNEY
I/We,
and
,
constituting the sole or all of the custodial  parent(s) or  court-appointed guardian(s) of the
child(ren) named below, and residing at
hereby appoint
(1)
, residing at
, with
telephone number(s)
and
having the following relationship(s) to  me  us  the minor(s):
; and
(optional) (2)
, residing at
, with
telephone number(s)
and
having the following relationship(s) to  me  us  the minor(s):
,
to serve as the short-term guardian(s) over, and health care agents for, the following minor child(ren)
(If
more space is needed here or elsewhere, attach additional sheets):
Full name:
DOB:
Full name:
DOB:
Full name:
DOB:
and will become effective (check one):
 immediately;
 on
,
, 201
;
 upon the deaths, incapacity, or absence of all parents/guardians listed above; or
 the occurrence of the following triggering event(s):
,
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