POWER OF ATTORNEY FOR CARE AND CUSTODY OF MINOR CHILD OR PROTECTED PERSON

I am the parent  	 protected person:

guardian 	

(check one) of the minor child(ren) or

 	, born on	 	
 	, born on	 	

(DOB)
(DOB)

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

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

Name	 	
Address		 City, State, Zip Code	 	

3.	CHOOSE/CHECK ONLY ONE OF THE FOLLOWING

 	   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. OR

 	  I delegate to my attorney-in-fact only the specific authority to:

4.	This Power of Attorney lasts until 	(date) (This date must be within 6 months of signing this Power of Attorney) or until the powers of the attorney in fact are revoked by me in writing.

5.	This Power of Attorney lasts even in the event of my disability or incapacity.

Dated this 	day of 	, 20 	.

_ 	(sign here)
 	  (Type or print name)
 	  (Address)
 	  (City, State, Zip)

Signed and sworn to before me this 	day of 	, 20 	

In 	(city), 	(county), 	(state).

Notary Public