or legal custodian powers. A. The following statutory form of power of attorney to delegate parental or legal authority as authorized by Section 1 of this act is legally sufficient: Statutory Form for Power of Attorney to Delegate Parental or Legal Custodian Powers 1. "I certify that I am the parent or legal custodian of: _____________________________________ ___________________________ (Full name of minor child) (Date of birth) _____________________________________ ___________________________ (Full name of minor child) (Date of birth) _____________________________________ ___________________________ (Full name of minor child) (Date of birth) (minor child(ren))." 2. "I designate ___________________________________________________, (Full name of Attorney-in-fact) ___________________________________________________________________, (Street address, city, state and zip code of Attorney-in-fact) _________________________________ _________________________________ (Home phone of Attorney-in-fact) (Work phone of Attorney-in-fact) as the attorney-in-fact of each minor child named above." 3. _______"I delegate to the attorney-in-fact all of my power and authority regarding the care, custody and property of each minor child named above, including but not limited to the right to enroll the child in school, inspect and obtain copies of education records and other records concerning the child, the right to attend school activities and other functions concerning the child, and the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function or treatment that may concern the child. This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child." or 4. _______"I delegate to the attorney-in-fact the following specific powers and responsibilities (write in): ____________________________________________________________________ This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on or for the child, or the termination of parental rights to the child." 5. "This power of attorney is effective for a period not to exceed one year, beginning _______________, 20__, and ending ______________, 20__. I reserve the right to revoke this authority at any time." By:__________________________________ (Parent/Legal Custodian signature) 6. "I hereby accept my designation as attorney-in-fact for ____________________________________________________________________ (Minor child(ren)) as specified in this power of attorney." _______________________________ (Attorney-in-fact signature) State of ____________ County of ___________ ACKNOWLEDGEMENT Before me, the undersigned, a Notary Public, in and for said County and State on this _____ day of ___________________, 20__, personally appeared _____________________________ (Name of Parent/Legal Custodian) and ___________________________ (Name of Attorney-in-fact), to me known to be the identical persons who executed this instrument and acknowledged to me that each executed the same as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument. Witness my hand and official seal the day and year above written. _______________________________ (Signature of notarial officer) (Seal, if any) ______________________________ (Title and Rank) My commission expires: ___________ B. The power of attorney is legally sufficient under this act, if the wording of the form complies substantially with subsection A of this section, the form is properly completed, and the signatures of the parties are acknowledged.
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