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

NOTICE
The purpose of this power of attorney is to give the person you designate (your "agent") broad powers to handle your property, which may include powers to sell or otherwise dispose of any real or personal property without advance notice to you or approval by you.
This power of attorney does not impose a duty on your agent to exercise granted powers, but, when powers are exercised, your agent must use due care to act for your benefit and in accordance with this power of attorney.
Your agent may exercise the powers given here throughout your lifetime, even after you become incapacitated, unless you expressly limit the duration of these powers or you revoke these powers or a court acting on your behalf terminates your agent's authority.
Your agent must act in accordance with your reasonable expectations to the extent actually known by your agent and, otherwise, in your best interest, act in good faith and act only within the scope of authority granted by you in the power of attorney.
The law permits you, if you choose, to grant broad authority to an agent under power of attorney, including the ability to give away all of your property while you are alive or to substantially change how your property is distributed at your death. Before signing this document, you should seek the advice of an attorney at law to make sure you understand it.
A court can take away the powers of your agent if it finds your agent is not acting properly.
The powers and duties of an agent under a power of attorney are explained more fully in 20 Pa.C.S. Ch. 56.
If there is anything about this form that you do not understand, you should ask a lawyer of your own choosing to explain it to you.
I have read or had explained to me this notice and I understand its contents.
Signature of Principal                                                          
Printed Name                                                                         
Date 				

1.	
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	 	

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), Pennsylvania.

Notary Public