Power Of Attorney For Care Of A Minor Child Page 2
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5(____) the physical or mental condition of the parent or legal guardian or the child
is such that care and supervision of the child cannot be provided;
(____) the loss or uninhabitability of the child’s home as a result of a natural
disaster;
(____) the need for medical or mental health treatment (including substance abuse
treatment) by the parent or legal guardian; or,
(____) other (please describe) _________________________________________
___________________________________________________________.
7. (____) I/We the undersigned, authorize the named caregiver to do one or more of
the following:
(_____) enroll the child in school and extracurricular activities (including
but not limited to Boy Scouts, Boys & Girls Club),
(_____) obtain medical, dental, and mental health treatment for the child,
and
(_____) provide for the child’s food, lodging, housing, recreation and
travel.
(____) I/We grant the following additional power to the named caregiver: ______
____________________________________________________________
___________________________________________________________.
8. (____) I/We understand that this document does not provide legal custody to the
caregiver. If at any time I/we disagree with a decision of the named
caregiver or choose to make any healthcare or educational decisions for
my/our child, I/we must revoke the power of attorney, in writing, and
provide written documentation to the health care provider and the local
education agency (i.e., school).
9. (____) I/We understand that this document may be terminated in another written
document signed by either parent with legal custody or by any order of a
court with competent jurisdiction.
Part II: To be initialed by caregiver.
10. (____) I understand that this document, properly executed, gives me the right to
enroll the minor child in the local education agency serving the area where
I reside.
11. (____) I understand that this document does not provide me with legal custody.
12. (____) I understand that, prior to enrollment, the local education agency may
require documentation of the minor child’s residence with a caregiver
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