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Special Power of Attorney for Medical Authorization Form

  	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and shall remain   in full force and effect until ___________(8)_______________ or unless specifically extended or   rescinded earlier by either party.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)___