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Power of Attorney for a Minor
When you need to assign legal authority to an individual so that they may act on behalf of a minor child then you will want to use this template. Enter the details regarding the child into the blank fields after you after revised the form so that meets your requirements regarding the rights you are assigning.

Free Sample Template
Format: Word PDF
# of Pages: 2
Printable: Yes


Power of Attorney for a Minor TemplateForm 4165
Format: Word PDF
Category: Legal, Power of Attorney
Type: POA Agreement

Power of Attorney for a Minor

Effective Date: ___/___/_____

I hereby declare that I am the Parent and / or Legal Guardian,

Parent Name: __________________________________________________________________________________

Date of Birth: __________________________________________________________________________________

Social Security Number: __________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________ State: __________ Zip Code: _____________________________

Of this minor Child,

Name of Child: _________________________________________________________________________________

Date of Birth: __________________________________________________________________________________

Social Security Number: __________________________________________________________________________

___ Same address as above

Address: ______________________________________________________________________________________

City: ____________________________________ State: __________ Zip Code: _____________________________

I appoint the following Caregiver as my true and lawful attorney in fact to act in my name and place in the event that I may be unable and a decision must be made and or authorization given for the above listed child regarding the following: medical treatment, recreational or religious activities, matters relating to education, or in any other situations that may involve my child. I hereby authorize the Caregiver in such an event to take all of the steps as I would do or could do if I were personally present and able. I hereby understand that this Minor Power of Attorney shall terminate six months from the date of it being executed and that I may renew it at that time.

Caregiver Name: _______________________________________________________________________________

Social Security Number: __________________________________________________________________________

Address: ______________________________________________________________________________________

City: ____________________________________ State: __________ Zip Code: _____________________________

I hereby declare that under the penalty of perjury under the laws of the state of _____________ that the foregoing is true and correct.

Parent Signature: _____________________________________________________________Date: ___/___/_____

Print Parentís Name: ____________________________________________________________________________




Notary Public Acknowledgement:

SEAL

This affidavit was subscribed, sworn to and acknowledged before me this, the _____________ day of the month of

___________________________________, 2______.

Signature of Notary Public: _______________________________________________________________________

My Commission Expires: ___/___/_____