I, ___________(1)___________, of
__________(2)_________, hereby appoint ______________(3)________________
of ___________(4)_______________, as my attorney in fact to act in my
capacity to do any and all of the following:
1. Make any and all decisions and authorize all
procedures that _____(5)____ may deem necessary regarding the medical
treatment of my children, _____(6)_____ and/or ______(7)______.
The rights, powers, and authority of my attorney
in fact to exercise any and all of the rights and powers herein granted
shall commence and be in full force and effect and shall remain in full
force and effect until ___________(8)_______________ or unless
specifically extended or rescinded earlier by either party.
Dated ___________(9)______________, 19_(10)_.
____________(11)______________
STATE OF _______(12)____________
COUNTY OF ______(13)____________
BEFORE ME, the undersigned authority, on this
_(14)_ day of _______(15)________, 19_(16)_, personally appeared
___________(17)___________ to me well known to be the person described
in and who signed the Foregoing, and acknowledged to me that he executed
the same freely and voluntarily for the uses and purposes therein
expressed.
WITNESS my hand and official seal the date
aforesaid.
__________(18)_________________
NOTARY PUBLIC
My Commission Expires:__(19)___
NOTICE
The information in this document is designed to
provide an outline that you can follow when formulating business or
personal plans. Due to the variances of many local, city, county and
state laws, we recommend that you seek professional legal counseling before
entering into any contract or agreement.
