POWER OF ATTORNEY FOR
CARE AND CUSTODY OF MINOR CHILD(REN)

1.		I am the parent 	guardian 	(check one) of the minor child(ren) or protected person:
 	 whose date of birth is 	(DOB)
 	 whose date of birth is 	(DOB)

2.	My address is 	(street address),
 	(city, state and zip code)

I appoint the following person as my attorney-in-fact for the minor child(ren)/protected person named above in paragraph 1:

Name	 	
Address		 City, State, Zip Code	 	

a.	To participate in decisions regarding the child(ren)’s education including attending conferences with the teachers or any other educational authorities, granting permission for the child(ren)’s participation in school trips and other activities, and making any other decisions and executing any documents with respect to the child(ren)’s education.

b.	To grant consent for the child(ren) to participate in any activity which the attorney-in- fact feels appropriate

c.	To make health care decisions on behalf of the child(ren), including decisions about medical, dental, optometric, or mental health care, whether routine or emergency in nature, including admissions to hospitals or other institutions. To refuse, consent or withdraw consent for any care, tests, treatment, and surgery procedure to diagnose or treat physical or mental conditions. To examine the child(ren)’s medical records and to consent to the disclosure of those records where the attorney-in-fact thinks it’s appropriate.

d.	To generally act and execute all other documents which may be necessary or proper to see to the needs of the child(ren).

e.	EXCLUDED SPECIFICALLY FROM THE AUTHORITY AND POWERS GRANTED TO THE ATTORNEY-IN-FACT:

-	Power or authority to consent to the marriage or adoption of the chid(ren)
-	 	
-	 	
-	 	

The powers granted to the attorney-in-fact shall be in effect until 	,
20 	(not to exceed six months) or until such time as the undersigned revokes this
document and the powers of the attorney-in-fact in writing.

Dated this 	day of 	, 20 	.

 	  (sign here)
 	  (type or print name)
 	  (address)
 	  (city, state, zip code)

Signed and sworn to before me this 	day of 	, 20 	
In 	(city), 	(county) 	(state).

Notary Public