Minor Child Power of Attorney Form

Location

What County is this Power of Attorney document being signed?

County

State

The Minor

Name of Minor Child

First

Last

Minor Child Date of Birth

The Parent(s)

Who is creating this power of attorney?

Father's Name

First

Last

Mother's Name

First

Last

Mailing Address(es)

Do the parents live together?

Parent's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Father's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Mother's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Father's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Mother's Mailing Address

Street Address

Address Line 2

City

State

ZIP Code

Attorney-in-Fact

Name of Attorney-in-Fact

First

Last

Who is the person that will have decision-making powers over the minor child?

Is the Attorney-in-Fact related to the Minor Child?

Select Relation

Write the relation between the Minor and Attorney-in-Fact

Attorney-in-Fact Mailing Address

Attorney-in-Fact Address

Street Address

Address Line 2

City

State

ZIP Code

Do you want the Attorney-in-Fact to have the power to:

What powers will the Attorney-in-Fact have over the Minor? (check all that apply)

Choose a school, view educational records, and to approve of any after-school activities.Provide food, clothing, shelter, and everyday care for the child’s physical and emotional well-being.View medical records and make any type of health care decision.Travel anywhere in the USA.

Are there any other powers the Principal would like to grant?

Write any additional powers you would like the Attorney-in-Fact to have

Restrictions/Limitations

Will the Principal have any specific restrictions on the Attorney-in-Fact's power?

Restrictions on the Attorney-in-Fact

Begin and End Date

When will this power of attorney begin?

Date when the power of attorney will begin

When will this minor power of attorney terminate?

Date

Execution

Who will witness the signatures of this power of attorney?

This form is required to be sign in front of either:

Two (2) witnesses not related to the parents or the minor child

or

A notary public. A notary public is a State appointed representative that can be found at any branch bank or credit union (usually free if you have an account with them).