Whereas, ______________ is the parent and guardian of the

following child(ren):

_____________________________________________________________

I designate ______________ of _______, _____ to act as guardian of

the minor child(ren) stated above upon my incapacity to so act.

Should ______________ be unable or unwilling to serve, I nominate

_____________ of__________, _______ to act as the guardian of the

minor children in the place of _________________.

Upon my disability, the designated guardian shall have the

following authority:

a) residential custody of the minor child(ren);

b) to approve medical treatment of any kind or type or to

disapprove the same within the bounds of the law;

c) to designate schooling for the minor children, and access to

any and all of their educational records;

d) to generally act in loco parentis.

In the event that I am the custodian of any property for the minor

children under the Uniform Transfer to Minor's Act, or the Uniform

Gifts to Minors Act or similar statute, I designate the guardian

or successor guardian to act as custodian for all such custodial

property.

In the event that formal legal proceedings are commenced to

establish a guardian for the child, it is my desire that the

guardians mentioned herein have priority in appointment.

The failure to list an individual as a guardian or successor

guardian is intentional.

Dated: __________________________

________________________________________________________________

Principal(s)

STATE OF __________

COUNTY OF _________

Before me, the undersigned authority personally appeared the above

signatory (signatories) who acknowledged to me execution of this

durable power of attorney.

___________________________________________________________