POWER OF ATTORNEY FOR CARE OF A MINOR CHILD Use of this ...

POWER OF ATTORNEY FOR CARE OF A MINOR CHILD 

Use of this form is authorized by T.C.A.§ 34-6-301 et seq. Completion of this form, along 

with the proper signatures, is sufficient to authorize enrollment of a minor in school and to 

authorize medical treatment. However, a school district may require additional 

documentation/information as permitted by this section of Tennessee law before enrolling a 

child in school or any extracurricular activities. Please print clearly. 

Part I: To be filled out and/or initialed by parent(s). 

1. Minor Child’s Name _________________________________________________ 

2. Mother/Legal Guardian’s Name & Address ______________________________ 

______________________________ 

______________________________ 

3. Father/Legal Guardian’s Name & Address ______________________________ 

_______________________________ 

_______________________________ 

4. Caregiver’s Name & Address ______________________________ 

______________________________ 

______________________________ 

5. (____) Both parents are living, have legal custody of the minor child and have signed this 

document; 

OR 

(____) One parent is deceased; 

OR 

(____) One parent has legal custody of the minor child and both parents have 

signed this document and consent to the appointment of the caregiver; 

OR 

(____) One parent has legal custody of the minor child, and has sent by Certified Mail, 

Return Receipt requested, to the other parent at last known address, a copy of this 

document and a notice of the provisions in § 34-6-305; or the non-custodial parent 

has not consented to the appointment and consent cannot be obtained because 

______________________________. 

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6. Temporary care-giving authority regarding the minor child is being given to the caregiver 

because of the following type of hardship (check at least one): 

(____) the serious illness or incarceration of a parent or legal guardian; 

(____) the physical or mental condition of the parent or legal guardian or the child is such 

that care and supervision of the child cannot be provided; 

(____) the loss or inhabitability of the child’s home as a result of a natural disaster; 

(____) the need for medical or mental health treatment (including substance abuse treatment) 

by the parent or legal guardian; or, 

(____) other (please describe) __________________________________________________ 

__________________________________________________________________________. 

7. (____) I/We the undersigned, authorize the named caregiver to do one or more of the 

following: 

(_____) enroll the child in school and extracurricular activities (including but not limited to 

Boy Scouts, Boys & Girls Club), 

(_____) obtain medical, dental, and mental health treatment for the child, 

and 

(_____) provide for the child’s food, lodging, housing, recreation and travel. 

(____) I/We grant the following additional power to the named caregiver: _______________ 

__________________________________________________________________________ 

__________________________________________________________________________. 

8. (____) I/We understand that this document does not provide legal custody to the caregiver. 

If at any time I/we disagree with a decision of the named caregiver or choose to make any 

healthcare or educational decisions for my/our child, I/we must revoke the power of attorney, 

in writing, and provide written documentation to the health care provider and the local 

education agency (i.e., school). 

9. (____) I/We understand that this document may be terminated in another written 

document signed by either parent with legal custody or by any order of a court with 

competent jurisdiction. 


Part II: To be initialed by caregiver. 

10. (____) I understand that this document, properly executed, gives me the right to enroll the 

minor child in the local education agency serving the area where I reside. 

11. (____) I understand that this document does not provide me with legal custody. 

12. (____) I understand that, prior to enrollment, the local education agency may require 

documentation of the minor child’s residence with a caregiver and/or documentation or other 

verification of the validity of the stated hardship. 

13. (____) I understand that, except where limited by federal law, I shall be assigned the 

rights, duties, and responsibilities that would otherwise be assigned to the parent, legal 

guardian or legal custodian pursuant to Tennessee Code Annotated Title 49. 

14. (____) I understand that, if the minor child ceases to reside with me, I am required by law 

to notify any person, school or health care provider to whom I have given this document. 

Part III: To be initialed by parent(s) and caregiver. 

15. (____) (____) We understand that, by accepting the power of attorney, if we enroll a 

student in a school system while fraudulently representing the child’s current residence or the 

parents’ hardship or circumstances for using the power of attorney, either or both of us is 

liable for restitution to the school district for an amount equal to the per pupil expenditure for 

the district in which the student is fraudulently enrolled. Restitution shall be cumulative for 

each year the child has been fraudulently enrolled in the system and may include costs and 

fees related to litigation. 

I/We declare under penalty of perjury under the laws of the State of Tennessee that the 

foregoing is true and correct. 

STATE OF _____________ ) 

COUNTY OF __________ ) 

______________________________ 

Mother/Legal Guardian 

Date: ______________ 

The Mother/Legal Guardian, ______________________, personally appeared before 

me this _____ day of ____________, 20______. 

______________________________ 

My commission expires: 

___________________ 

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NOTARY PUBLIC

STATE OF ____________ ) 


______________________________ Date: ______________ 

Father/Legal Guardian 

The Father/Legal Guardian, ______________________, personally appeared before 

me this _____ day of ____________, 20_____. 

______________________________ 

NOTARY PUBLIC 


___________________ 

STATE OF _____________ ) 


______________________________ Date: ______________ 

Caregiver 

The Caregiver, ______________________, personally appeared before me this _____ day of 

____________, 20_____. 

______________________________ 

NOTARY PUBLIC 


___________________ 

NOTICE TO THE LOCAL EDUCATION AGENCY AND/OR HEALTH 

CARE PROVIDER: 

Pursuant to T.C.A. § 34-6-308, no person, school official or health care provider who acts 

in good faith reliance on a power of attorney for care of a minor child to enroll the child 

in school or to provide medical, dental or mental health care, without actual knowledge of 

facts contrary to those authorized, is subject to criminal or civil liability to any person, or 

is subject to professional disciplinary action for such reliance. This section shall apply 

even if medical, dental, or mental health care is provided to a minor child or the child is 

enrolled in a school in contravention of the wishes of the parent with legal custody of the 

minor child, as long as the person, school official or health care provider has been 

provided a copy of an appropriately executed power of attorney for care of a minor child, 

and has not been provided written documentation that the parent has revoked the power 

of attorney for care of a minor child. 

Additionally, pursuant to T.C.A. § 34-6-310, a person who relies on the power of attorney for 

care of a minor child has no obligation to make any further inquiry or investigation. Nothing 

in this part shall relieve any individual from liability for violations of other provisions of law.

POWER OF ATTORNEY FOR CARE OF A MINOR CHILD Use of this ...

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