Parental Power of Attorney Form
Parental Power of Attorney Form
Please complete this form to authorize another individual to make decisions regarding the care and welfare of your child(ren) for a specified period of time.
Parent/Guardian Information
Name
Address
Phone Number
Attorney-in-Fact (Agent) Information
Name
Relationship to Child(ren)
Address
Phone Number
Child(ren) Information
Child’s Name
Date of Birth
Child’s Name
Date of Birth
Child’s Name
Date of Birth
Powers Granted
The Attorney-in-Fact (Agent) is authorized to make decisions on behalf of the parent/guardian in the following areas:
-
Medical and Healthcare Decisions
-
Educational Decisions (School Enrollment, Permissions, etc.)
-
Travel and Recreational Activities
-
General Childcare and Daily Needs
-
Effective Date
Termination Date
This power of attorney will remain in effect until:
Parent/Guardian’s Signature
Name:
Date:
Attorney-in-Fact’s (Agent’s) Signature
Name:
Date:
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