Power Of Attorney Form - Joint Legal Decision-Making Parents And Minor Child printable pdf download

POWER OF ATTORNEY

Re: Care, Custody, and Property of Minor Child

Joint Legal Decision-Making Parents

Minor Child

Name:

____________________________

______________________________

Primary Residence:

Other Residence:

Medical Problems or Allergies:

____________________________

_____________________________

______________________________

____________________________

_____________________________

______________________________

Telephone: __________________

Telephone: ___________________

Date of Birth: ___________________

Parents, as adults who are the parents of Minor Child and are joint legal decision-makers for Minor Child, hereby

constitute and appoint Attorney-in-Fact to act in the name and place of Parents, and as the true and lawful attorney

for Parents as follows:

1. To consent to and authorize any emergency medical, surgical, or dental care, or any hospitalization which

Attorney-In-Fact deems necessary or advisable for the health or treatment of any illness or injury of Minor Child.

2. To consent to and authorize any educational services and make any education-related decisions that Attorney-

In-Fact deems necessary or advisable for the education and welfare of Minor Child.

This Power of Attorney shall not be affected by the disability or incompetence of the Parents and shall expire six

months after date of execution of this document by the Parents, unless terminated sooner. Either of the Parents

may revoke this Power of Attorney by delivering written notice to Minor Child’s school.

We, the Parents, sign our names to this Power of Attorney this _______day of ____________________,

___________, and, being first duly sworn, do declare to the undersigned authority, that we execute it as our free

and voluntary act for the purposes expressed in the Power of Attorney, and that we are eighteen years of age or

older, of sound mind, and under no constraint or undue influence.

Signature of Parent

SUBSCRIBED AND SWORN or affirmed and acknowledged before me on:

and

My Commission Expires:

Notary Public

ACCEPTANCE OF APPOINTMENT

I accept my appointment as Attorney-In-Fact of the Minor Child.

_______________________________________

Date: ____________________________________

Attorney-In-Fact

Printed Name: ___________________________

Telephone: _______________________________

Residence: _____________________________

Other Contact Information:

_______________________________________

_________________________________________

Revised July 1, 2014

Power Of Attorney Form - Joint Legal Decision-Making Parents And Minor Child

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