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    Camille Jane Roan Esporlas
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    SPA

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    Copyright:

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    235 views2 pages

    Power of Attorney Minor Form

    Uploaded by

    Camille Jane Roan Esporlas
    SPA

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    POWER OF ATTORNEY FOR

    CARE AND CUSTODY OF MINOR CHILD(REN)

    1. I am the parent ______ guardian_____ (check one) of the minor child(ren) or protected
    person:
    ________________________ whose date of birth is ______________________ (DOB)
    ________________________ whose date of birth is ______________________ (DOB)

    2. My address is __________________________________(street address),


    __________________________________(city, state and zip code)

    I appoint the following person as my attorney-in-fact for the minor child(ren)/protected


    person named above in paragraph 1:

    Name ________________________________________
    Address ________________________________________
    City, State, Zip Code ________________________________________

    a. To participate in decisions regarding the child(ren)’s education including attending


    conferences with the teachers or any other educational authorities, granting permission
    for the child(ren)’s participation in school trips and other activities, and making any
    other decisions and executing any documents with respect to the child(ren)’s education.

    b. To grant consent for the child(ren) to participate in any activity which the attorney-in-
    fact feels appropriate

    c. To make health care decisions on behalf of the child(ren), including decisions about
    medical, dental, optometric, or mental health care, whether routine or emergency in
    nature, including admissions to hospitals or other institutions. To refuse, consent or
    withdraw consent for any care, tests, treatment, and surgery procedure to diagnose or
    treat physical or mental conditions. To examine the child(ren)’s medical records and to
    consent to the disclosure of those records where the attorney-in-fact thinks it’s
    appropriate.

    d. To generally act and execute all other documents which may be necessary or proper to
    see to the needs of the child(ren).
    e. EXCLUDED SPECIFICALLY FROM THE AUTHORITY AND POWERS GRANTED TO THE
    ATTORNEY-IN-FACT:

    - Power or authority to consent to the marriage or adoption of the chid(ren)


    - ____________________________________________
    - ___________________________________________
    - ___________________________________________

    The powers granted to the attorney-in-fact shall be in effect until __________________,


    20____ (not to exceed six months) or until such time as the undersigned revokes this
    document and the powers of the attorney-in-fact in writing.

    Dated this __________ day of _______________________, 20_____.

    _________________________ (sign here)


    _________________________ (type or print name)
    _________________________ (address)
    _________________________ (city, state, zip code)

    Signed and sworn to before me this ______ day of ___________________, 20_____


    In _________________(city), _____________________ (county) _________________ (state).

    ______________________________
    Notary Public

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