SPECIAL POWER OF ATTORNEY

AND ACCEPTANCE

I, ______and ______, as the legal custodial parents of ______(herein the “Child”), hereby appoint ______as the Child’s custodian and as my Attorney-in-Fact to act as follows:

To enroll in school and generally supervise the education of; to act in loco parentis in providing for the general health, welfare, and education of the Child; to have full authority to take any appropriate action, including authorization for educational or medical services, in the interests of the Child.

I further agree to assume responsibility for any fees or other charges relating to the Child’s education in the Uintah School District and, if eligibility for fee waivers is claimed, I agree to provide the district with all financial information requested by the district for the purpose of determining eligibility for fee waivers.

This Special Power of Attorney shall terminate upon the revocation by the grantor or grantee, or by order of the court of competent jurisdiction, when the Child reaches the age of 18, marries, or becomes emancipated; or upon the following date ______, whichever occurs first.

This Special Power of Attorney does not confer legal guardianship. The district may, but is not required to, accept this Special Power of Attorney.

Unless sooner revoked by me or terminated by law, this Power of Attorney shall be terminated only upon notice to my Attorney-in-Fact of my death in accordance with Utah Code Annotated 75-5-502. This Power of Attorney shall not be affected by disability of the principal (UCA 75-5-501).

DATED this _____ day of ______, 201_.

______

(Custodial Parent)

______

(Custodial Parent)

State of )

: ss

County of )

On the _____ day of ______, 201_, personally appeared before me, a Notary Public for the State of ______, ______, and acknowledged to me that ______and ______executed the within instrument the date and year first above written.

______

Notary Public for the State of

Residing at:

My Commission expires:

ACCEPTANCE

The undersigned accepts the appointment as Custodian of the above Child and as Attorney-in-Fact of the grantor and agrees to assume responsibility for fees or other charges relating to the Child’s education in the Uintah School District and if eligibility for fee waivers is claimed, I agree to provide the district with all financial information requested by the district for the purpose of determining eligibility for fee waivers.

DATED this _____ day of ______, 201_.

______

(Custodian)

State of )

: ss

County of )

On the _____ day of ______, 201_, personally appeared before me, a Notary Public for the State of ______, ______, and acknowledged to me that ______executed the within instrument the date and year first above written.

______

Notary Public for the State of

Residing at:

My Commission expires:

Revised 08/13/02

UINTAH SCHOOL DISTRICT

Statement of Residency

Date: ______

I/We, ______the parent/guardian(s) of ______(Prospective Student(s), residing at ______in Uintah County, verify that we are permanent residents of the State of Utah, Uintah School District. The above named student lives with the above named parent/guardian at the above address who will provide responsible supervision for the student while attending Uintah School District.

DATED this _____ day of ______, 201_.

______

Parent/Guardian(s) Signature Parent/Guardian(s) Signature

State of Utah )

: ss

County of Uintah )

On this _____ day of ______, 201_, before me ______, a notary Public, personally appeared ______, and proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument.

______

Notary Public for the State of Utah

My Commission expires:

Utah Code: 76-8-504: Written False Statement. A person is guilty of a class B misdemeanor if: With intent to deceive a public servant in the performance of his official function he/she: Makes any written false statement which he/she does not believe to be true or falsely represents his/her status.

Revised 08/13/02

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