1. I am [PARENT / GUARDIAN NAME], the ☐ parent ☐ legal guardian (check one) of the minor child(ren):

[MINOR CHILD NAME] (name); date of birth [MM/DD/YYYY]
[MINOR CHILD NAME] (name); date of birth [MM/DD/YYYY]

2. My address is [STREET ADDRESS], [CITY/STATE/ZIP CODE]

3. I appoint the following person as my attorney-in-fact for the minor child(ren) named above in paragraph 1:

Name: [ATTORNEY-IN-FACT NAME]
Address: [ATTORNEY-IN-FACT STREET ADDRESS]
City, State, Zip Code: [ATTORNEY-IN-FACT CITY/STATE/ZIP CODE]

4. I delegate to my attorney-in-fact the power and authority:

a. To participate in decisions regarding the child(ren)’s or 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 child(ren).

[ENTER OTHER EXCLUDED AUTHORITIES]

5. The powers granted to the attorney-in-fact shall be in effect until [MM/DD/YYYY] (not to exceed six months) or until such time as the undersigned revokes this document and the powers of attorney-in-fact in writing.

Dated this _____ day of _______, 20____

Parent/Guardian Signature: _______________________
Print Name: _______________________
Address: _______________________ City/State/Zip Code: _____________________ Telephone Number: _____________

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

Signed and sworn to before me on ______, 20______ by

_______________________________________
(Notary Public or Clerk of Court)
If Notary, my commission expires: ____________