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Louisiana ___ Notary Public -3- ic in and for the parish / county and state aforesaid, this __________ day of ________________________________________________ , __________. ____________________________________________________________________. ______________________________________________________________ Notary Public STATE OF LOUISIANA, COUNTY / PARISH OF _________________________: SWORN TO AND SUBSCRIBED before me, Notary Publ______________________: SWORN TO AND SUBSCRIBED before me, Notary Public in and for the parish / county and state aforesaid, this __________ day of ________________________________________________ , ________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ STATE OF LOUISIANA, COUNTY / PARISH OF ___ess Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ____in-Fact. Signed on ________________ (date), at _______________________ (city), Louisiana. ________________________________ Signature of Father ________________________________ Signature of Mother Witnhis document, without notice of such termination, shall be held harmless. -2- We may revoke this Power of Attorney before the expiration date at any time by providing written notice to the Attorney-ms that arise against the third party because of reliance on this power of attorney. If this Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of t act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. We agree to indemnify the third party for any clai then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. Any third party who receives a copy of this document mayall reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If any part of this document is held to be invalid, illegal or unenforceable under applicable law,erein. We hereby ratify and confirm all acts by the Attorney-in-Fact done by virtue of this power of attorney and the rights hereby granted. The Attorney-in-Fact shall be entitled to reimbursement of ("expiration date"). By signing here, we indicate that we are fully informed as to the contents of this document and understand the full import of this grant of powers to the Attorney-in-Fact named h consent to the marriage of our child/children; (iii) have the power to consent to the adoption of our child/children. This power of attorney shall be in effect from _______________ to _______________standing other provisions in this Power of Attorney, Attorney-in-Fact shall not (i) have the authority to withhold or withdraw life sustaining procedures for any child/children; (ii) have the power tor the performance of the powers granted by this document, including but not limited to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents. Notwith other insurance for our child/children and to make and file any medical or other type of claim against any health or other type of insurance company. 6. Endorse and execute any documents necessary fof of our child/children and to adjust, compromise and settle any claim, our child/children may have against any other person or entity. 5. Apply for, purchase, maintain and/or deal with any health andng, but not limited to, provisions of living quarters, food, clothing, entertainment and other customary matters. -1- 4. Request, ask, demand, sue and take any and all legal steps necessary on behaln; allow our child/children to participate in activities and events offered by any group, organization or educational facility. 3. Maintain the customary living standard of the child/children, includine the education of our child/children and to register and enroll our child/children in any educational programs, schools and extracurricular activities; review any school records of the child/childre care to our child/children. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2. Determihe contents of any medical records; execute any consent, release or waiver of liability required by medical, dental or other health authorities incident to the provision of medical, surgical or dentaline any health care at any hospital or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose ts necessary or desirable for maintaining the health, education, and welfare of our above named child/children, including, but not limited to, the powers to: 1. Provide for, approve, authorize and decl___ born on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fact shall have the power and authority to act entirely in loco parentis and to do all act__________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: ______________________________lawful agent and attorney-in-fact for us and in our name, and in our behalf to act as the guardian of our minor child/children: Name: _________________________________ born on __________ Name: _______________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintaining an address at: _____________________________________________________ as our true and ________________________________ ("Father") and ______________________________________ ("Mother"), jointly referred to as "Parents" or "Principals", maintaining an address at: ________________________ the Attorney-in-Fact assumes the fiduciary and other legal responsibilities of an agent. -3- POWER OF ATTORNEY FOR THE CARE OF CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: We ______________________pon you. If you have any questions about these powers, obtain competent legal advice. You may revoke this power of attorney at any time. ATTORNEY-IN-FACT: By accepting or acting under the appointment, and control the care, custody, health and welfare of your child/children. Any such action undertaken by the Attorney-in-Fact, within the scope of this power of attorney document, is legally binding uhe Care of Children document are broad and sweeping. Before signing this document, consider its consequences. You ("Parents") are providing another person ("Attorney-in-Fact") with the power to handlepropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PARENTS: The powers granted by this Power of Attorney for tea to do so. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever apll make it more difficult for any third party to challenge the validity of the Power of Attorney. Although, some states don't require that a Power of Attorney be witnessed, it is always a very good id can revoke the document at any time even before the expiration date. The Power of Attorney for the Care of Children should always be notarized, even if your state does not require it. Notarization wicareful in instructing the Attorney-in-Fact as to what the Attorney-in-Fact should do. Although the Power of Attorney for the Care of Children has a beginning and an "end/expiration" date, the Parentsl in the selection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweeping and the children are being entrusted to the Attorney-in-Fact. The Parents should also be , dental or any other type of care. Medical personnel will also generally feel more comfortable dealing with an Attorney-inFact who can provide this type of document. The Parents should be very carefuype of document available, the Attorney-in-Fact will be able to better deal with any types of emergency involving the children and can avoid potential problems when, for example, arranging for medicalarent will be absent for a period of time. The powers granted by this instrument are very broad. Parents are basically giving temporary custody of the children to the Attorney-infact. By having this tpower of attorney. This form allows the Attorney-in-Fact to make decisions for the children in place of the parents, including health care, education and welfare decisions. This can be useful if the pney" is not used here to mean "lawyer". The person acting as the Attorney-in-Fact for the Parents or the children does not need to be a lawyer. Almost anyone can be appointed an Attorney-in-Fact by a document allows parents of one or more children (sometimes called the "Principals" or "Grantors") to appoint another person to act as their Attorney-in-Fact to care for their children. The word "attor of Attorney for the Care of Children Whenever it becomes necessary to allow someone else to provide for the care of your children, a Power of Attorney for the Care of Children form can be used. This hould not be used without consulting with an attorney first. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Powers the powers granted by this document are very broad and sweeping. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and sct or Notary should not be a witness. [_] The Parents should be careful giving instructions to the Attorney-in-Fact. The Parents should also be very careful in the selection of the Attorney-in-Fact, a required, it is always a good idea to also have two witnesses sign the Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Parents, Attorney-in-Fahould keep a copy of the Power of Attorney for the Care of Children document for their records. [_] At least one witness should sign the Power of Attorney for the Care of Children. Although not alwaysthe Power of Attorney for the Care of Children document before a Notary. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact. [_] The Parents s(3) additional useful information about Power of Attorney for the Care of Children documents. [_] Both Parents need to sign the Power of Attorney for the Care of Children. [_] The Parents should sign Instructions & Checklist Louisiana Power of Attorney for the Care of Children [_] This package contains a (1) Power of Attorney for the Care of Children; (2) simple instructions plus a checklist; and Louisiana