Power of Attorney, Simple

_______________________________________________________________, the parent of

_____________________________________________________________, herewith appoints
______________________________ of _____________________________, as their attorney
in fact, to act in the place and stead and with the same authority as Principal would have to do
the following acts:
To act as the guardian of the person of my minor children:
______________________________________________________________________.
including the right to act entirely in loco parentis; including the authority to approve or to decline
medical treatment of any kind for the child and including the right to review medical records or
school records of the child.
This power of attorney shall be in effect from ________________ to ___________________.
_____________________________________________________
_______________________________, As Principal
STATE OF ______________________
COUNTY OF _______________________
_______________________________ personally appeared before me and acknowledged the
execution of this power of attorney for the purposes set forth therein.
Dated: _______________________________
__________________________________________
Notary Public
Commission Expires:

Power of Attorney, Simple

Review List
This review list is provided to inform you about this document in question and assist you in its
preparation. This is a simple but powerful Power of Attorney for care of your children that has a
specific time period. An important feature of this form is the automatic termination date at the
end of the period. You can adapt this Power of Attorney to relate to many matters where you
want someone to serve as your proxy.

1. Make sure to limit the time period in the document itself for your own protection.
Remember, you can always renew the Power of Attorney, should you want to do so.

2. A notary is suggested to be sure the Power of Attorney is honored in a crisis. Authorities

love the legal niceties; this gives it to them so your agent with the Power of Attorney can
act promptly and effectively.