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Special Power Of Attorney For Medical Authorization

I, ________, of _________, hereby appoint _________ of ________, 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 _____ may deem necessary regarding the medical treatment of my children, _______ and/or _______.

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be in full force and effect and shall remain in full force and effect until _______ or unless specifically extended or rescinded earlier by either party.

Dated this _____ day of ____, 20 _.

________________________

STATE OF _______________

COUNTY OF ______________

BEFORE ME, the undersigned authority, on this __ day of ____, 20 _, personally appeared _____ 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.

________________________

NOTARY PUBLIC

My Commission Expires: ____