POWER OF ATTORNEY
Re: Care, Custody, and Property of Minor Child
Joint Custody Parents
Medical Problems or Allergies:
Date of Birth: ___________________
Parents, as adults who are the parents of Minor Child and have joint legal custody of Minor Child, hereby constitute
and appoint Attorney-in-Fact to act in the name and place of Parents, and as the true and lawful attorney for
Parents as follows:
1. To consent to and authorize any emergency medical, surgical, or dental care, or any hospitalization which
Attorney-In-Fact deems necessary or advisable for the health or treatment of any illness or injury of Minor Child.
2. To consent to and authorize any educational services and make any education-related decisions that Attorney-
In-Fact deems necessary or advisable for the education and welfare of Minor Child.
This Power of Attorney shall not be affected by the disability or incompetence of the Parents and shall expire six
months after date of execution of this document by the Parents, unless terminated sooner. Either of the Parents
may revoke this Power of Attorney by delivering written notice to Minor Child’s school.
We, the Parents, sign our names to this Power of Attorney this _______day of ____________________,
___________, and, being first duly sworn, do declare to the undersigned authority, that we execute it as our free
and voluntary act for the purposes expressed in the Power of Attorney, and that we are eighteen years of age or
older, of sound mind, and under no constraint or undue influence.
Signature of Parent
Signature of Par