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Maine ame typed, printed, or stamped -4- or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ N__________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to meon. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped State of MAINE ) ) ss County of ______ me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identificati_ City: __________________________________ State: ___________________________________ -3- State of MAINE ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before____________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ____________________________________ (city), Maine. ________________________________ Signature of Father ________________________________ Signature of Mother Witness Signature: ___________________________________ Name: _______________d harmless. We may revoke this Power of Attorney before the expiration date at any time by providing written notice to the Attorney-in-Fact. Signed on ________________ (date), at _____________________his power of attorney. If this Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be helctive as to a third party until the third party has actual knowledge of the revocation. We agree to indemnify the third party for any claims that arise against the third party because of reliance on tll remain in full force and effect and not be affected by any partial invalidity. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effeny provision of this Power of Attorney. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaffected parts of the document shall stin-Fact done by virtue of this power of attorney and the rights hereby granted. The Attorney-in-Fact shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out a 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 herein. We hereby ratify and confirm all acts by the Attorney-i to consent to the adoption of our child/children. This power of attorney shall be in effect from _______________ to _______________ ("expiration date"). -2- By signing here, we indicate that we aret shall not (i) have the authority to withhold or withdraw life sustaining procedures for any child/children; (ii) have the power to consent to the marriage of our child/children; (iii) have the powerbut not limited to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents. Notwithstanding other provisions in this Power of Attorney, Attorney-in-Facical or other type of claim against any health or other type of insurance company. 6. Endorse and execute any documents necessary for the performance of the powers granted by this document, including im, our child/children may have against any other person or entity. 5. Apply for, purchase, maintain and/or deal with any health and other insurance for our child/children and to make and file any medlothing, entertainment and other customary matters. 4. Request, ask, demand, sue and take any and all legal steps necessary on behalf of our child/children and to adjust, compromise and settle any clavents offered by any group, organization or educational facility. 3. Maintain the customary living standard of the child/children, including, but not limited to, provisions of living quarters, food, coll our child/children in any educational programs, schools and extracurricular activities; review any school records of the child/children; allow our child/children to participate in activities and e be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2. Determine the education of our child/children and to register and enrse or waiver of liability required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to our child/children. Health care shall include but notoy any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent, relea, and welfare of our above named child/children, including, but not limited to, the powers to: 1. Provide for, approve, authorize and decline any health care at any hospital or other institution; emplon __________ -1- The above named Attorney-in-Fact shall have the power and authority to act entirely in loco parentis and to do all acts necessary or desirable for maintaining the health, education_________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born behalf to act as the guardian of our minor child/children: Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _____________________________ ("Attorney-in-Fact") maintaining an address at: _____________________________________________________ as our true and lawful agent and attorney-in-fact for us and in our name, and in our__________________ ("Mother"), jointly referred to as "Parents" or "Principals", maintaining an address at: ________________________________________ hereby make and appoint ___________________________t you do not understand, you should ask a lawyer to explain it to you. KNOW ALL PERSONS BY THESE PRESENTS: We ______________________________________________________ ("Father") and ____________________r the Care of Children, you may be liable for damages and may be subject to criminal prosecution. If there is anything about this Power of Attorney for the Care of Children or your duties under it thahority under this Power of Attorney for the Care of Children will end on the termination date or sooner if revoked by the Principals. If you violate your fiduciary duty under this Power of Attorney for a duty (called a "fiduciary duty") to observe the standards observed by a prudent person. The duty is explained more fully in the Maine Revised Statutes and in Maine case law. As the Agent, your auterms of this Power of Attorney for the Care of Children. This Power of Attorney for the Care of Children is valid only if the Principals are of sound mind when they sign it. As the Agent, you are undeAgent" or "Attorney-in-Fact," you are given power under this Power of Attorney for the Care of Children to make decisions about the health, welfare and care of the Principals' in accordance with the tChildren at any time. If there is anything about this Power of Attorney for the Care of Children that you do not understand, you should ask a lawyer to explain it to you. Notice to the Agent: As the " of the powers that you give your Agent are explained more fully in the Maine Revised Statutes, and in Maine case law. You have the right to revoke or take back this Power of Attorney for the Care of ten Power of Attorney for the Care of Children does not limit the powers that you give your Agent, your Agent will have broad and sweeping powers without advance notice to you or approval by you. SomeGeneral Power of Attorney to grant power to another person (called the "Agent" or "Attorney-in-Fact") to make decisions about the health, welfare and care of your children on your behalf. If this writ Attorney-in-Fact assumes the fiduciary and other legal responsibilities of an agent. -3- POWER OF ATTORNEY FOR THE CARE OF CHILDREN Notice to the Principals: As the "Principal," you are using this 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, the 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 upon are 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 handle andriate, 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 the Co 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 appropake 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 idea t 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 will mful 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 Parents can 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 carental 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 careful inof 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 medical, det 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 type r 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 paren 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 powement 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 "attorney"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 docud 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 Power of e 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 shoulr 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, as thuired, 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-Fact od 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 always reqPower 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 shouladditional 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 the Instructions & Checklist Maine 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 (3) Maine