I, [PARENT/GUARDIAN’S NAME], parent or guardian of the minor child(ren) or incapacitated person(s) named below:

Full Name: [CHILD’S NAME]
Date of Birth: [CHILD’S DATE OF BIRTH]
Relationship: [DESCRIBE RELATIONSHIP]

I hereby authorize and appoint [ATTORNEY-IN-FACT’S NAME], as Attorney-in-Fact for me with full authority to act in my place as follows:

1. To perform any and all acts necessary for the day-to-day care, custody, education, recreation, and property of the above-named minor child or incapacitated person, consistent with the provision of § 15-14-105, C.R.S.
2. To authorize any and all medical and dental care for the health and well being of the minor child(ren) or incapacitated person(s). This care includes, but is not limited to medical and dental exams and tests, x-rays, surgeries, anesthesia, and hospital care.

This Special Power of Attorney does not give the Attorney-in-Fact the power to consent to the marriage or adoption of the child or incapacitated person.

This Special Power of Attorney shall be effective until [DATE] unless revoked earlier by the parent or guardian in writing. In any case, the authority granted herein shall not be valid for more than 12 months from the date of this document.

Parent/Guardian Signature: _______________________
Date: ______________

Subscribed and affirmed, or sworn to before me in the County of ______________, State of ______________, this ______ day of ______________, 20 ______.

Notary Public/Clerk: _______________________
My Commission Expires: ______________