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Pennsylvania d/children. ______________________________ Signature of Agent _______________________________ Date -5- en separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal and the chilwer of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal and the child/children. I shall keep the assets of the principal and the child/childr______, have read the attached power of attorney and am the person identified as the Agent for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the po_____________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- Acknowledgment by Agent I, _______________________________________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ______________________________________ State: ___________________________________ State of PENNSYLVANIA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of __y: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: ________________ _______________________ (city), Pennsylvania. ________________________________ Signature of Parent Witness Signature: ___________________________________ Name: ___________________________________ Cition, shall be held harmless. -3- I 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 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 this document, without notice of such terminattorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party becausedocument 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 may act under it. Revocation of the power of at 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, then the remaining unaffected parts of the 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 all reasonable expenses incurred as a result indicate that I am 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. I hereby ratify and confirm all acts (iii) have the power to consent to the adoption of any of the child/children. This power of attorney shall be in effect from _______________ to _______________ ("expiration date"). By signing here, Ittorney-in-Fact 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 any of the child/children;nt, including but not limited to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents. Notwithstanding other provisions in this Power of Attorney, Ad file any medical 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 docume any claim, the child/children may have against any other person or entity. -2- 5. Apply for, purchase, maintain and/or deal with any health and other insurance for the child/children and to make an food, clothing, entertainment and other customary matters. 4. Request, ask, demand, sue and take any and all legal steps necessary on behalf of the child/children and to adjust, compromise and settlees and events 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, and enroll the child/children in any educational programs, schools and extracurricular activities; review any school records of the child/children; allow the child/children to participate in activiti but not be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2. Determine the education of the child/children and to registert, release or waiver of liability required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child/children. Health care shall includeon; employ 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 conseneducation, and welfare of my 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 instituti-named minor child/children: 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, aining an address at: _____________________________________________________ as, my true and lawful agent and attorney-in-fact for me and in my name, and in my behalf to act as the guardian of my above____________________________ born on __________ Name: _________________________________ born on __________ I hereby make and appoint ________________________________________ ("Attorney-in-Fact") maint __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _____Parent"), maintaining an address at: ________________________________________. I am an adult and I am the custodial parent having full legal custody of: Name: _________________________________ born onrantor _________________________________ Name of Principal / Grantor __________________________ Date -1- KNOW ALL PERSONS BY THESE PRESENTS: I, ___________________________________________________ ("HOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / GS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SERE UNTIL THE EXPIRATION DATE, UNTIL YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND THE BENEFIT OF THE CHILDREN AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HNDLE THE HEALTH, CARE AND WELFARE OF YOUR CHILD/CHILDREN WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT Wof an agent. -3- POWER OF ATTORNEY FOR THE CARE OF CHILDREN NOTICE TO PRINCIPAL / GRANTOR: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HA advice. You may revoke this power of attorney at any time. ATTORNEY-IN-FACT: By accepting or acting under the appointment, the Attorney-in-Fact assumes the fiduciary and other legal responsibilities y such action undertaken by the Attorney-in-Fact, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legalument, consider its consequences. You ("Parent") are providing another person ("Attorney-in-Fact") with the power to handle and control the care, custody, health and welfare of your child/children. Anle, generally include state specific instructions. -2- CAUTION! PARENT: The powers granted by this Power of Attorney for the Care of Children document are broad and sweeping. Before signing this doct a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sathe Power of Attorney. Although, some states don't require that a Power of Attorney be witnessed, it is always a very good idea to do so. Please note that this information is not intended as and is noower of Attorney for the Care of Children should always be notarized, even if your state does not require it. Notarization will make it more difficult for any third party to challenge the validity of t should do. Although the Power of Attorney for the Care of Children has a beginning and an "end/expiration" date, the Parent can revoke the document at any time even before the expiration date. The P document are very broad and sweeping and the children are being entrusted to the Attorney-in-Fact. The Parent should also be careful in instructing the Attorney-in-Fact as to what the Attorney-in-Facy feel more comfortable dealing with an Attorney-inFact who can provide this type of document. The Parent should be very careful in the selection of the Attorney-in-Fact, as the powers granted by thiseal with any types of emergency involving the children and can avoid potential problems when, for example, arranging for medical, dental or any other type of care. Medical personnel will also generallrument are very broad. The Parent is basically giving temporary custody of the children to the Attorneyin-fact. By having this type of document available, the Attorney-in-Fact will be able to better ds for the children in place of the Parent, including health care, education and welfare decisions. This can be useful if the Parent will be absent for a period of time. The powers granted by this insty-in-Fact for the Parent or the children does not need to be a lawyer. Almost anyone can be appointed an Attorney-in-Fact by a power of attorney. This form allows the Attorney-in-Fact to make decisionppoint another person to act as his or her Attorney-in-Fact to care for the child/children on a temporary basis. The word "attorney" is not used here to mean "lawyer". The person acting as the Attornee of Children form can be used. This document allows a single parent (sometimes called the "Principal" or "Grantor") of one or more children, who has full/sole legal custody of the child/children to af Attorney for the Care of Children (Single Parent / One Custodial Parent) Whenever it becomes necessary to allow someone else to provide for the care of your children, a Power of Attorney for the Card should not be used without consulting 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 o, as 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 an Children document for his or her records. [_] The Parent should be careful giving instructions to the Attorney-in-Fact. The Parent should also be very careful in the selection of the Attorney-in-Factldren document. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact. [_] The Parent should keep a copy of the Power of Attorney for the Care ofbeginning of the Power of Attorney document. [_] In Pennsylvania, the Agent (i.e. the Attorney-in-Fact) will have to sign the Acknowledgement at the bottom of the Power of Attorney for the Care of ChiThe witnesses must not be under 18 and should not be related by blood or marriage to the Principal, Agent or Notary. [_] In Pennsylvania, the Principal must also sign the "Notice to Principal" at the ly competent and must sign the document before a Notary. [_] In Pennsylvania, the Power of Attorney also needs to be signed in the presence of two witnesses (who will also have to sign the document). e parent with full/sole legal custody) needs to sign the Power of Attorney for the Care of Children. [_] In Pennsylvania, the Principal (i.e. the parents granting the power of Attorney) must be mentalsimple instructions plus a checklist; and (3) additional useful information about Power of Attorney for the Care of Children - (Single Parent / One Custodial Parent). [_] The Custodial Parent (i.e. onInstructions & Checklist Pennsylvania Power of Attorney for the Care of Children (Single Parent / One Custodial Parent) [_] This package contains a (1) Power of Attorney for the Care of Children; (2) Pennsylvania