Fillable POWER OF ATTORNEY OVER CHILD

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POWER OF ATTORNEY OVER CHILD

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POWER OF ATTORNEY OVER CHILD
STATE OF TEXAS §
COUNTY OF ______________ §
BEFORE ME, the undersigned notary public, personally came and
appeared ____________________ , of ______________________________ who,
(Print name -parent/guardian) (Print -address of parent/guardian)
after being duly sworn, declared that he/she is the parent/guardian of the minor
child, _________________________, DOB ________________________ and,
(Print legal name of minor child) (Print date of birth of said minor child)
desires that the custody of the aforesaid child be changed to:
_______________________________, ___________________________________
(Print name of individual who is assuming custody)(address of assuming adult) (city, state, zip)
The child will reside with _______________________________________
(Print name)
_______________________________________________
(Print Address, city, state, zip)
The Affiant acknowledges that he/she is surrendering his/her rights only for the limited
purposes of residence and that the adult assuming custody SHALL have the following
rights, powers and duties:
The power to consent to medical and surgical treatment during an emergency
involving an immediate danger to the health and safety of the child.
The power and duty to enroll the child in school.
To provide the child with clothing, food and shelter.
To have physical custody of said child, including the duty of care, control,
protection and reasonable discipline of the child.
This Power of Attorney must be renewed each year and is uni-laterally revocable upon thirty
(30) days written notice of affiant.
_____________________________________
Affiant (parent/guardian signature)
_____________________________________
Printed Name of Affiant
SWORN TO AND SUBSCRIBED BEFORE ME this _____ day of ______________, 20___.
_____________________________________
Notary Public in and for the State of Texas
_____________________________________
PRINTED NAME OF NOTARY
My Commission expires: ________________
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ACCEPTANCE OF TEMPORARY CUSTODIAL CARE OF
MINOR BY ATTORNEY-IN-FACT
HOME TELEPHONE:
PLEASE PRINT
AGENT'S NAME:
WORK TELEPHONE:
CELL PHONE OR PAGER:
This document applies to the following minor child(ren):
NAME
DOB
NAME
DOB
NAME
DOB
The parent/legal guardian of minor(s) is:
NAME
TELEPHONE
ADDRESS
CITY, ZIP
By my signature hereto, under the authority of Texas Family Code, Section 35.01, I accept the authorization given by
the above-named parent to act in their stead for any of the following matters listed below:
• Authorizing any medical, dental, and/or surgical treatment during an emergency involving an immediate danger
to the health and safety of the child.
• Enrolling the child in school.
• Providing the child with clothing, food, and shelter.
• Having physical custody of said child, including the duty of care, control, protection, and reasonable discipline
of the child.
I understand that this Power of Attorney must be renewed each year and is uni-laterally revocable upon thirty (30)
days written notice of affiant.
I hereby agree to waive all claims and hold harmless any institution, its administrators and staff from all claims arising
from their reliance on this consent form. I understand that this is not a grant of legal guardianship, which only a court
may grant.
Signed this _________ day of ___________________________, 20________.
__________________________________
SIGNATURE OF ATTORNEY-IN-FACT
_____________________________________
PRINTED NAME OF ATTORNEY-IN-FACT
STATE OF TEXAS §
COUNTY OF ____________ §
Subscribed and sworn to me by ____________________________________ on this
the ________ day of _____________________________, 20_______.
______________________________________ _______________________________
SIGNATURE OF NOTARY PRINTED NAME OF NOTARY
OFFICE USE ONLY:
APPROVED BY: _______________________________________________ DATE: _______________
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POWER OF ATTORNEY OVER CHILD

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Completed 18 January 2022

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