(1) I am the ☐ parent ☐ court-appointed guardian of [MINOR CHILD NAME], who was born on [MM/DD/YYYY].

(2) I appoint the following person as my attorney-in-fact for the person named in Paragraph (1).

Name: [ATTORNEY-IN-FACT NAME]
Address: [ATTORNEY-IN-FACT STREET ADDRESS]
City, State, ZIP: [ATTORNEY-IN-FACT CITY/STATE/ZIP]
Phone: [ATTORNEY-IN-FACT PHONE]
E-mail: [ATTORNEY-IN-FACT EMAIL]

(Check (3) OR (4), not both. If you check (4), describe the authority being delegated.)

(3) ☐ – I delegate to my attorney-in-fact all power and authority that I have as a parent or guardian, except the power to consent to marriage or adoption.

(4) ☐ – I delegate to my attorney-in-fact only the specific authority to: [DESCRIBE POWERS]

(5) This power of attorney lasts until [MM/DD/YYYY]. (This date must be within the next 6 months.)

(6) ☐ – This power of attorney lasts even in the event of my disability.

Date: ______________ Parent/Guardian Signature: _______________________

Typed or printed name: [PARENT/GUARDIAN NAME]
Address: [PARENT/GUARDIAN STREET ADDRESS]
City, State, ZIP: [PARENT/GUARDIAN CITY/STATE/ZIP]
Phone: [PARENT/GUARDIAN PHONE]
E-mail: [PARENT/GUARDIAN EMAIL]

On this date, I certify that [PARENT/GUARDIAN NAME], who is known to me or who presented satisfactory identification in the form of [FORM OF IDENTIFICATION], has, while in my presence and while under oath or affirmation, voluntarily signed this document and declared that it is true.

Date: ______________ Notary Public Signature: _______________________

Typed or printed name: [NOTARY PUBLIC NAME]

[Notary Seal]