Power Of Attorney Delegating Parental Power Page 2

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The parental power I am delegating is as follows:
FULL
(Check the box if you want to delegate full parental power regarding the care and custody of
the child(ren) named above.)
Full parental power regarding the care and custody of the child(ren) named above
PARTIAL
(Check each subject over which you want to delegate your parental power regarding the
child(ren) named above.)
HEALTH CARE DECISIONS DELEGATED AS FOLLOWS:
The power to consent to all health care; or
The power to consent to only the following health care:
Ordinary or routine health care, excluding major surgical procedures, extraordinary
procedures, and experimental treatment
Emergency blood transfusion
Dental care
Disclosure of health information about the child(ren)
OTHER DECISIONS DELEGATED AS FOLLOWS:
The power to consent to educational and vocational services.
The power to consent to the employment of the child(ren).
The power to consent to the disclosure of confidential information, other than health
information, about the child(ren).
The power to provide for the care and custody of the child(ren).
The power to consent to the child(ren) obtaining a motor vehicle operator's license.
The power to travel with the child(ren) outside the state of Wisconsin.
The power to obtain substitute care, such as child care, for the child(ren).
Other specifically delegated powers or limits on delegated powers
(Fill in the following space or attach a separate sheet describing any other specific powers that you
wish to delegate or any limits that you wish to place on the powers you are delegating.)
__________________________________________________________________________________
__________________________________________________________________________________
SEE ATTACHED PAGE(S)
This delegation of parental powers does not deprive a custodial or noncustodial parent of any of his
or her powers regarding the care and custody of the child, whether granted by court order or force of
law.
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