Special Power of Attorney for Medical Authorization

9/6/2013

I, ___________(1)___________, of __________(2)_________,
hereby appoint ______________(3)________________ of
___________(4)_______________, as my attorney in fact to act
in my capacity to do any and all of the following:

1. Make any and all decisions and authorize all procedures
that _____(5)____ may deem necessary regarding the medical
treatment of my children, _____(6)_____ and/or
______(7)______.

The rights, powers, and authority of my attorney in fact to
exercise any and all of the rights and powers herein granted
shall commence and be in full force and effect and shall
remain in full force and effect until
___________(8)_______________ or unless specifically extended
or rescinded earlier by either party.

Dated ___________(9)______________, 20_(10)_.

      ____________(11)______________


STATE OF _______(12)____________

COUNTY OF ______(13)____________

BEFORE ME, the undersigned authority, on this _(14)_ day of
_______(15)________, 20_(16)_, personally appeared
___________(17)___________ to me well known to be the person
described in and who signed the Foregoing, and acknowledged to
me that he executed the same freely and voluntarily for the
uses and purposes therein expressed.

WITNESS my hand and official seal the date aforesaid.

                          __________(18)_________________
                                            NOTARY PUBLIC

                          My Commission Expires:__(19)___

##Notice##

The information in this document is designed to provide an
outline that you can follow when formulating business or
personal plans.  Due to the variances of many local, city,
county and state laws, we recommend that you seek professional
legal counseling before entering into any contract or
agreement.

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