NOTARIZED DURABLE POWER OF ATTORNEY, LETTER OF PERMISSION TO TRAVEL, MEDICAL CONSENT FORM
1. We, and, of [county], Michigan, give this durable power of attorney, letter of permission to travel, medical consent form (Consent) pursuant to section 5103 of the Estates and Protected Individuals Code, MCL 700.5103. We delegate all of our parental rights regarding the care, custody, and property of our for our child, [name] (ssn: [Social Security number]; dob: [date of birth]), to [name] OR [name].
2. This Consent will be effective from [date], to [name], unless revoked in writing before ending date.
3. We grant full permission for our child to travel with [name] or [name] including to and from [place].
4. We delegate to [name] or [name] all our parental rights regarding the care, custody, and property of our child, for our child regarding any circumstances, including any accident or illness, which may necessitate medical treatment, and on our behalf to authorize any such treatment or surgery that [he / she / they], in their sole discretion, may deem necessary. Medical treatment for our child may also include dental surgery, X-ray, blood transfusion, anesthetic, and medication, provided any such medical treatment is performed by a duly licensed practitioner.
5. Persons responsible should please note the following:
[Please list any existing: prescriptions or other medication currently being administered, allergies, tendency towards abnormal bleeding, epilepsy, etc.]
6. The following information is essential in case of medical treatment or hospitalization: Name and address of employer; medical aid /insurer; policy number:
______
______
7. We agree to be bound by any lawful act done by [name] or [name], and we, our heirs, legal and personal representatives, and assigns, accept full liability for all costs incurred because of such medical treatment for our child.
8. This Consent will not be affected by our disability except as provided by statute.
9. Reproductions of this executed original (with reproduced signatures) will be deemed to be original counterparts of this Consent.
PARENTS/GUARDIANS SIGNATURES:
Parent/Guardian ______Date: [date]
Address: [address]
Phone number: [phone number] E-mail address: [e-mail address]
NOTARY PUBLIC SIGNATURE:
Subscribed and sworn to before me this [date].
(SEAL)
Notary’s Signature
Notary Public in and for the [county], [state].
Parent/Guardian: ______Date: [date]
Address: [address]
Phone number: [phone number] E-mail address: [e-mail address]
NOTARY PUBLIC SIGNATURE:
Subscribed and sworn to before me this [date].
(SEAL)
Notary’s Signature
Notary Public in and for the [county], [state].