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Special Power of Attorney for Child Care Form

 SPECIAL POWER OF ATTORNEY FOR CHILD CAREI/We, ________________________________________________________
the parents and/or legal guardians of the following named minor children:
_____________________________________________________________ _____________________________________________________________
residing at _____________________________________________________ _____________________________________________________________
do hereby name, constitute, nominate and appoint the following person(s) to have our
Special Power of Attorney for the temporary care of my/our minor child(ren):
____________________________________________________________ ________________________________________________________________________________________________________________________ The power(s) granted under this Special Power of Attorney are those which I/We have initialed below: ________ The power to care for and make and authorize all medical,
dental and other healthcare decisions regarding the care of
my/our minor child(ren) named herein.
________ Medical and Dental powers shall be limited to emergencies only. ________ Other: _____________________________________________
________ To do any and all acts on behalf of or for the benefit of my/our minor child(ren) that I/We could do under law as the parent(s) or legal guardian(s).
This Special Power of Attorney is a durable power of attorney and shall not be affected by my/our mental or physical incapacity. This Special Power of Attorney shall become effective at the time where I/We have initialed below: ________ On the ____ day of _______________, ________ Or ________ Immediately upon it's be signed, witnessed and notarized. This Special Power of Attorney shall terminate not later than six months from the date it was signed, or earlier when it is revoked in writing or on the ____ day of ________________, ________, whichever occurs first. I/We, _______________________________________________________, the principal(s), sign my/our name(s) to this Special Power of Attorney this ____ day of ________________, _________, and being first duly sworn, do declare to the undersigned authority that I/We sign and execute this instrument as my/our Special Power of Attorney and that I/We sign it willingly, or willing direct another to sign it for me/us, that I/We execute it as my/our free and voluntary act for the purposes expressed in the Special Power of Attorney, and that I/We am/are eighteen years of age or older, of sound mind and under no constraint or undue influence. ________________________________________________
Signature of Maker Signature of Maker
Signed, sealed and delivered 
in the presence of: 
(Signature of witness) 
(Signature of witness)             
STATE OF _____________________ 
COUNTY OF ____________________ 
In _______________, on the _____________ day of ____________, 20 __, before me, a Notary Public in and for the above state and county, personally appeared ___________________, known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed.
                            NOTARY PUBLIC 
                            My Commission Expires: ________