1. I declare I am the PARENT and/or GUARDIAN,

PARENT NAME: [PARENT / GUARDIAN NAME]
BIRTH DATE: [MM/DD/YYYY]
SOCIAL SECURITY #: [SOCIAL SECURITY #]
CITY/STATE OF RESIDENCE: [CITY/STATE]

Of this minor CHILD,

CHILD NAME: [MINOR CHILD NAME]
BIRTH DATE: [MM/DD/YYYY]
SOCIAL SECURITY #: [SOCIAL SECURITY #]
CITY/STATE OF RESIDENCE: [CITY/STATE]

Pursuant to 45-5-104 NMSA, do hereby appoint this CAREGIVER, my true and lawful attorney in fact, to act in my name, place and stead, in the event that I am unavailable and a decision must be made and/or authorization given for the above named child regarding medical treatment, education matters, participation in religious or recreational activities or in any other matters involving my child. I authorize the Caregiver in this event to take any and all steps, as fully and for all intents and purposes as I might do or could do if personally present. I understand that pursuant to the statute this power of attorney terminates six months from the date executed and I may renew it at that time.

CAREGIVER NAME: [ATTORNEY-IN-FACT NAME]
BIRTH DATE: [MM/DD/YYYY]
SOCIAL SECURITY #: [SOCIAL SECURITY #]
CITY/STATE OF RESIDENCE: [CITY/STATE]

I declare under penalty or perjury under the laws of the state of New Mexico that the foregoing is true and correct.

Parent/Guardian Signature: _______________________ Date: ______________
Print Name: _______________________

Print Name: _______________________

NOTARY PUBLIC ACKNOWLEDGMENT

This affidavit was subscribed, sworn to, and acknowledged to me this, the _______ day of the month of ____________, 20___.

Notary Signature: _______________
Print Name: _______________
My Commission Expires: _______ (Notary Seal)