Power of Attorney to Authorize Medical Treatment 2007-2008 School Year

Today’s Date: ______

Termination Date of this Power:31st day of August, 2008

KNOW ALL PERSONS BY THESE PRESENTS, that I,

Parent’s full name: ______

Parent’s street address: ______

Parent’s City, State, Zip: ______

Parent’s Home Phone: ______

Parent’s Cell Phone: ______

Teen’s Full Name: ______

do hereby constitute and appoint the BEARER OF THIS DOCUMENT to be my true and lawful Attorney-in-Fact, for me and in my name, place, and stead, and for my use and benefit to make each and every judgment necessary for the proper and adequate medical and/or related care of my Minor Child and the power to give an informed consent or an informed refusal on my behalf with respect to their physical or mental health, care, and comfort, including specifically, but not limited to:

  1. Any medical care, diagnosis, surgical procedure, therapeutic procedure and/or other treatment of any type or nature;
  2. Any dental procedure;
  3. The admission to any hospital, medical center, emergency medical facility, or other medical treatment office or facility;
  4. The use of any drugs, medication, therapeutic devices, or other medicines or items related to his/her health;
  5. The execution of waivers, medical authorizations and such other approval as may be required to permit or authorize care which he/she may need;

And the power in general to take and authorize all acts with respect to his/her health and well-being, and to expend money or authorize incurring debt in connection therewith, to the same extent as I could if present in person.

I further give and grant unto my Attorney-in-Fact full power and authority to do and perform every act necessary and proper to be done in the exercise of any of the foregoing powers as fully as I might or could do if personally present, with full power of substitution and revocation, and I hereby ratify and confirm all that my Attorney-in-Fact shall lawfully do or cause to be done by virtue hereof.

Anyone relying on this grant of powers may rely on a duplicate copy hereof, such duplicate copy shall for all intents and purposes have the same legal effect as the original and may be presented as an original in any legal proceeding.

This is a durable Power-of-Attorney and it shall not terminate on disability of the principal. All power and authority herein above granted shall in any event terminate on the Termination Date of this Power.

If for any reason this Power-of-Attorney is deemed legally insufficient by a court of competent jurisdiction, then this document shall operate as my written consent to any medical procedure or treatment deemed reasonably necessary by any health care provider rendering services to my child.

Parent’s Signature:

Notarial Acknowledgment: / State of ______, County of ______/ Date: ______
The Foregoing instrument was acknowledged before me this ___ day of
______, 2007, by ______(parent’s name) / (SEAL)
My Commission
Expires ______/ Notary
Signature: ______