POWER OF ATTORNEY DELEGATING PARENTAL POWER
As authorized by s. 48.979, Wis. Stats.
NAME(S) OF CHILD(REN)
This power of attorney is for the purpose of providing for the care and custody of the following
child(ren):
NAME: ____________________________________
DATE OF BIRTH: _______________________
ADDRESS: __________________________________________________________________________
NAME: ____________________________________
DATE OF BIRTH: _______________________
ADDRESS: __________________________________________________________________________
NAME: ____________________________________
DATE OF BIRTH: _______________________
ADDRESS: __________________________________________________________________________
DELEGATION OF POWER TO AGENT
I, _______________________________________________________________________________,
PARENT NAME
PARENT ADDRESS
state that I have legal custody of the child(ren) named above. (Only a parent who has legal custody
may use this form.) A parent may not use this form to delegate parental powers regarding a child who is
subject to the jurisdiction of the juvenile court under s. 48.13, 48.14, 938.12, 938.13, or 938.14, Wis.
Stats.
I delegate my parental power to:
Name of agent: _____________________________________________________________________
Agent's address: ____________________________________________________________________
Agent's telephone number(s): _________________________________________________________
Agent's e-mail address or additional contacts: ____________________________________________
The Relationship of the agent to child(ren) is _____________________________________________
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