I certify that I am the parent or legal guardian of:

[MINOR CHILD NAME] [MM/DD/YYYY]

[MINOR CHILD NAME] [MM/DD/YYYY]

[MINOR CHILD NAME] [MM/DD/YYYY]

(minor child/ren”). I designate

[ATTORNEY-IN-FACT NAME] as [STREET ADDRESS], [HOME PHONE], [WORK PHONE], as the undersigned’s attorney-in-fact with respect to the minor child/ren under ORS 109.056.

☐ – I delegate to the attorney-in-fact all of my power and authority regarding the care, custody and property of the minor child/ren, including but not limited to the right to enroll the minor child/ren in school, inspect and obtain copies of education records and other records concerning the minor child/ren, the right to attend school activities and other functions concerning the minor child/ren, and the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function or treatment that may concern the minor child/ren. OR

☐ – I delegate to the attorney-in-fact the following specific powers and responsibilities:

[DESCRIBE POWERS]

The delegation does not include the power or authority of the attorney-in-fact to consent to the minor child/ren’s marriage or adoption.

SELECT ONE:

☐ – This power of attorney is effective for a period not to exceed six months, beginning [MM/DD/YYYY] and ending [MM/DD/YYYY]. I reserve the right to revoke this authority at any time.

☐ – I am in the US Armed Forces and have been called to active duty. This power of attorney is effective through my active duty period plus 30 days.

Parent/Guardian Signature: _______________________

I hereby accept my designation as attorney-in-fact for [MINOR CHILD/REN NAME] as specified in this power of attorney.

Attorney-in-Fact Signature: _______________________