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Text File  |  2022-08-26  |  2KB  |  74 lines
  1.  
  2.  
  3. "    The undersigned parent(s), \a, residing at "
  4. "
  5. " \b "
  6. " \c "
  7. " \d "
  8. " \e "
  9. "
  10.  
  11. " hereby appoint(s) \f, residing at "
  12. "
  13. " \g "
  14. " \h "
  15. " \i "
  16. " \j "
  17. "
  18. " as the legal guardian(s) of the person(s) of my child(ren): "
  19. "
  20. " \k "
  21. " \l "
  22. " \m "
  23. "
  24.  
  25. "     This guardianship shall begin on the \n day of \o, \p, and shall
  26. "remain in effect through the \q day of \r, \s."
  27. "
  28. "    The above named guardian(s) shall have the following powers: "
  29. "
  30.  
  31. "1. The power to seek appropriate medical treatment or attention on 
  32. "behalf of my child as may be required by the circumstances, including 
  33. "but not limited to, medical doctor and/or hospital visits. "
  34. "
  35.  
  36. "2. The power to authorize medical treatment or medical procedures in 
  37. "an emergency situation. "
  38. "
  39. "3. The power to make appropriate decisions regarding clothing, 
  40. "bodily nourishment, and shelter. "
  41. "
  42. "Signed on this \t day of \u, \v. "
  43. "
  44. "
  45. "
  46. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}
  47. " parent(s)
  48. "
  49. "
  50.  
  51. "STATE/COMMONWEALTH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} "
  52. "
  53. "COUNTY/BOROUGH/PARISH OF {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} "
  54. "
  55. "BEFORE ME, the undersigned authority, on this day personally appeared 
  56. "\a, known to me to be the person(s) whose name(s) is(are) subscribed 
  57. "to the foregoing instrument, and acknowledged to me that he(she)(they) 
  58. "executed said instrument for the purposes and consideration therein 
  59. "expressed. "
  60. "
  61. "GIVEN under my hand and seal of office on this {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} 
  62. "day of {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}, {CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}. "
  63. "
  64. "
  65. "
  66. "{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@}{CBM-@} "
  67. "
  68. "Notary Public's Signature "
  69. "
  70. "(seal/stamp) "
  71. "
  72. "
  73. "
  74. "