1. For the Minor named [MINOR CHILD NAME] born on [MM/DD/YYYY] (hereinafter known as the “Minor”), I, [PARENT / GUARDIAN NAME], the ☐ Parent or ☐ Court Appointed Guardian with a street address of [STREET ADDRESS],

And I, [CO-PARENT / GUARDIAN NAME], the ☐ Parent or ☐ Court Appointed Guardian with a street address of [STREET ADDRESS],

2. Hereby appoint [ATTORNEY-IN-FACT NAME] as the Attorney-in-Fact for the Minor who is their [RELATION TO CHILD] with a street address of [STREET ADDRESS], (hereinafter referred to as the “Attorney-in-Fact”).

3. I/We delegate to the Attorney-in-Fact the authority to [DESCRIBE AUTHORITY HERE].

4. This power of attorney document shall commence on [MM/DD/YYYY] and end on:

A. [INITIAL] ☐ – [MM/DD/YYYY].
B. [INITIAL] ☐ – In the event of my disability (incapacitation).
C. [INITIAL] ☐ – In the event of my death.

5. This power of attorney shall be governed under the laws in the State of Massachusetts and terminates any prior written form.

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

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

ACCEPTANCE BY ATTORNEY-IN-FACT

The undersigned Attorney-in-Fact acknowledges and executes this Power of Attorney, and by such execution does hereby affirm that I: (A) accept the appointment; (B) understand the duties under the Power of Attorney and under the law.

Attorney-in-fact Signature: _______________________ Date: ______________
Print Name: _______________________

AFFIRMATION BY WITNESSES

I witnessed the execution of this Power of Attorney by the Parent/Court Appointed Guardian(s), and I affirm that the Parent/Court Appointed Guardian(s) appeared to me to be of sound mind, was not under duress, and the Parent/Court Appointed Guardian(s) affirmed to me that he/she was aware of the nature of this Power of Attorney and signed it freely and voluntarily.

Witness Signature: _______________________ Date: ______________
Print Name: _______________________

Witness Signature: _______________________ Date: ______________
Print Name: _______________________