Power Of Attorney Delegating Parental Power Page 3

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THIS DOCUMENT MAY NOT BE USED TO DELEGATE THE POWER TO ALL OF THE FOLLOWING:
CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN),
THE PERFORMANCE OR INDUCEMENT OF AN ABORTION ON OR FOR THE CHILD(REN),
THE TERMINATION OF PARENTAL RIGHTS TO THE CHILD(REN),
THE ENLISTMENT OF THE CHILD(REN) IN THE U.S. ARMED FORCES, OR
TO PLACE THE CHILD(REN) IN A FOSTER HOME, GROUP HOME, OR INPATIENT TREATMENT
FACILITY.
EFFECTIVE DATE AND TERM OF THIS DELEGATION
This Power of Attorney takes effect on (day/month/year) _________________________, and will
remain in effect until (day/month/year) _______________________.
If no termination date is given or if the termination date given is more than one year after the
effective date of this Power of Attorney, this Power of Attorney will remain in effect for a period of one
year after the effective date, but no longer.
REVOCATION OF POWER OF ATTORNEY
This Power of Attorney may be revoked in writing at any time by a parent who has legal custody
of the child(ren) and such a revocation invalidates the delegation of parental powers made by this
Power of Attorney, except with respect to acts already taken in reliance on this Power of Attorney.
SIGNATURE(S) OF PARENT(S)
___________________________________
________________________________
MOTHER’S SIGNATURE
DATE
FATHER’S SIGNATURE
DATE
___________________________________
________________________________
MOTHER’S NAME PRINTED
FATHER’S NAME PRINTED
___________________________________
________________________________
MOTHER’S ADDRESS
FATHER’S ADDRESS
___________________________________
________________________________
MOTHER’S TELEPHONE NUMBER(S)
FATHER’S TELEPHONE NUMBER(S)
___________________________________
________________________________
MOTHER’S EMAIL ADDRESS
FATHER’S EMAIL ADDRESS
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