Childcare Power of Attorney Form

Where does the child currently reside?

This is important for State laws.

Which COUNTY does the child currently reside?

County

Which PARISH does the child currently reside?

Parish

A parent may not use this form to delegate parental powers regarding a child who is subject to the jurisdiction of the juvenile court under s. 48.13, 48.14, 938.12, 938.13, or 938.14, Wis. Stats.

A parent may not use this form to delegate parental powers regarding a child who is subject to the jurisdiction of the juvenile court under s. 48.13, 48.14, 938.12, 938.13, or 938.14, Wis. Stats. I understand.

Tennessee. For delegations of parental authority in Tennessee, use of a state-supplied form is required. The form may be downloaded at:

https://www.tn.gov/content/dam/tn/education/legal/legal_poa_minor_child_form.pdf

(1) If a child has another living parent whose whereabouts are known and who is willing and able to provide care and custody for the child, a parent may not leave the child with another person unless the other parent consents to the appointment in writing. (2) You may not appoint a temporary agent if your parental rights have been terminated or you have signed a voluntary surrender.

A power of attorney is not a valid means of delegating childcare authority in the state of Maryland. Please contact the clerk of your county court for information about temporary guardianship.

A power of attorney is not a valid means of delegating childcare authority in the state of Maryland. Please contact the clerk of your county court for information about temporary guardianship. I understand.

Will more than one child be covered by this power of attorney?

Will more than one child be covered by this power of attorney? One ChildMore than One Child

Number of children:

If you are concerned about your child's privacy, you may skip this step and enter their information with a pen after the form is printed.

Child's Name

Child's Date of Birth

2nd Child's Name

2nd Child's Date of Birth

3rd Child's Name

3rd Child's Date of Birth

4th Child's Name

4th Child's Date of Birth

5th Child's Name

5th Child's Date of Birth

Child's Name

Child's Date of Birth

Which statement is most applicable?

Which statement is most applicable? The person caring for my child(ren) is related by blood or by marriage.The person caring for my child(ren) is of no relation and I have reviewed their criminal history.

Does the person caring for your child(ren) have any criminal convictions?

Does the person caring for your child(ren) have any criminal convictions? YesNo

I have reviewed the agent's criminal history and I want them to be the agent because:

Name of the person that will care for the child(ren)

If a child is living with the other parent, this power of attorney must designate the other parent as their caregiver unless a court finds that it would not be in the best interest of the child.

If a child is living with the other parent, this power of attorney must designate the other parent as their caregiver unless a court finds that it would not be in the best interest of the child. I understand.

What is the parent's relationship to the person that will care for the child(ren)?

What is the caregiver's relationship to the child(ren)?

Address

Street Address

Address Line 2

City

State

ZIP Code

Phone

Work Phone

Cell Phone

What type of authority would you like to grant the caregiver?

What type of authority would you like to grant the caregiver? All of my parental authority. (The caregiver is authorized to act as your child's parent/guardian.) Only specific authorities. (The caregiver has only limited authority to care for your child.)

Please specify which authorities the caregiver will have:

The caregiver will only have authority over the items you list here.

Briefly explain the reasons for this transfer of authority:

Purpose of this power of attorney:

Purpose of this power of attorney: Personal or family reasonsMilitary deployment

Purpose of this power of attorney:

Purpose of this power of attorney: Personal or family reasonsMilitary deploymentGrandparent(s) will care for the child(ren)

Purpose of this power of attorney:

Purpose of this power of attorney: Personal or family reasons (maximum of 6 months)Grandparent(s) will care for the child or children (maximum of 3 years)Military deployment under state law (maximum of 12 months)Military deployment under federal law (maximum of deployment time plus 30days)

Members of the military may use either military option depending on the anticipated length of deployment.

Purpose of this designation:

Purpose of this designation: Personal or family reasonsChild(ren) will be left with an institution that provides professional careMilitary deployment

Purpose of this power of attorney:

Purpose of this power of attorney: Personal or family reasonsMilitary deployment under state lawMilitary deployment under federal law

Is the person caring for the child(ren) a school administrator?

Is the person caring for the child(ren) a school administrator? YesNo

This power of attorney:

This power of attorney: will begin and end on specified dates.will automatically become effective if I am incapacitated.

This power of attorney remains valid:

This power of attorney remains valid: until my health returns or as long as state law permits, whichever is sooner.for a specific period of time after I become incapacitated.

This power of attorney:

This power of attorney: will begin and end on specified dates.will automatically become effective if I am incapacitated.

This power of attorney remains valid:

This power of attorney remains valid: until my health returns or as long as state law permits, whichever is sooner.for a specific period of time after I become incapacitated.

This power of attorney:

This power of attorney: will begin and end on specified dates.will automatically become effective if I am incapacitated.

This power of attorney remains valid:

This power of attorney remains valid: until my health returns or as long as state law permits, whichever is sooner.for a specific period of time after I become incapacitated.

This power of attorney:

This power of attorney: will begin and end on specified dates.will automatically become effective if I am incapacitated.

This power of attorney remains valid:

This power of attorney remains valid: until my health returns or as long as state law permits, whichever is sooner.for a specific period of time after I become incapacitated.

This power of attorney:

This power of attorney: will begin and end on specified dates.will automatically become effective if I am incapacitated.

This power of attorney remains valid:

This power of attorney remains valid: until my health returns or as long as state law permits, whichever is sooner.for a specific period of time after I become incapacitated.

How long will it remain valid for?

Under state law, "service member" means (i) a member of the Armed Forces of the United States, (ii) a member of the Armed Forces Reserves, (iii) a member of the National Guard, (iv) a member of the commissioned corps of the National Oceanic and Atmospheric Administration, (v) a member of the commissioned corps of the U.S. Public Health Services, or (vi) any person otherwise required to enter or serve in the active military services of the United States under a call or order of the President of the United States or to serve on state active duty.