California Power of Attorney Care & Custody of Child or Children


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                             This Power Of Attorney for Care of Children is intended to provide for the appointment of an
                             Attorney-in-Fact to take care of the principal's children and to make decisions regarding the
                             children's education and health care. This form grants the Attorney-in-Fact the right to
                             participate in decisions regarding the children's education and health care and to sign
                             documents regarding such matters. This power of attorney excludes the authority to
                             consent to the marriage or adoption of the children. It contains some of the standard
                             powers typically included in a power of attorney for care of children, but can be customized
                             to fit the specific needs of the principal. This document should be used by individuals
                             located in California to appoint an Attorney-in-Fact for the care of their children.

                           OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND COMPLETENESS. They are for general guidance and should be modified by you or your
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                                   POWER OF ATTORNEY:



That pursuant to [STATUTE] I, _______________________________ [Instruction: Insert the
name of the principal] (hereinafter referred to as “Principal”), residing at
______________________________________ [Instruction: Insert the address of principal]
execute this Durable Power of Attorney and do hereby make, constitute, and appoint:
___________________________________ [Instruction: Insert the name of agent] (hereinafter
referred to as "Attorney-in-Fact"), residing at __________________________ [Instruction:
Insert the address of agent], as my Attorney-in-Fact TO ACT IN MY NAME, PLACE, AND
STEAD in any lawful way with respect to the care and custody of my child(ren): [Instruction:
Insert the name of child(ren)]

   a. _______________________________

   b. _______________________________

   c. _______________________________

   d. _______________________________

1. Effectiveness of Power of Attorney: This instrument is to be construed and interpreted as a
   General Durable Power of Attorney for the following purposes:

       a. To participate in decisions regarding my children, their education including attending
          conferences with their teachers or any other educational authorities, granting
          permission for their participation in school trips and other activities, and making any
          other decisions and executing any documents pertinent to their education.

       b. To endorse and execute any document necessary for 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.

       c. To grant permission and consent to my children participating in any activity
          sponsored by any group, association, or organization which activity my Attorney-in-
          Fact may deem appropriate.

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       d. To make health care decisions on behalf of my children, including making decisions
          regarding their medical or dental care, whether routine or emergency in nature,
          including admissions to hospitals or other institutions; to consent to, to refuse to
          consent to, or to withdraw consent to the provision of any care, tests, treatment,
          surgery, service, or procedure to maintain, diagnose, or treat a physical or mental
          condition, as well as the right to sign such medical forms as may be necessary to
          carry out such decisions; to talk with health care personnel who may be treating my
          child(ren) and to examine their medical records and to consent to the disclosure of
          such records in circumstances Attorney-in-Fact may deem appropriate; to file claims
          for medical insurance and to obtain information from any insurance company with
          respect to any policy of health or medical insurance under which my child(ren) are
          insured; provided however, that my Attorney-in-Fact shall not be required to execute
          any documents which would involve incurring any personal liability for any such
          treatment and care, and I affirm that I will be responsible for payment for any such
          care or treatment consented to by my Attorney-in-Fact that is not covered by

       e. To request, ask, demand, sue, and take any or all legal steps necessary on behalf of
          my child(ren)

2. Effective Date: This Power of Attorney shall become effective when I sign and execute it
   below. Unless sooner revoked or terminated by me, this Power of Attorney shall become null
   and void on this ____ [Month] ____ [Date], 20____ [Year] [Instruction: Insert the
   expiration date].

3. Period: This Power of Attorney shall remain in full force and effect until the date stated in
   Paragraph 2, and any party dealing with my Attorney-in-Fact during such time shall be fully
   protected and is hereby discharged, released, and indemnified from so doing in respect of any
   matter relating hereto unless such particular party shall have received prior notice in writing
   of the revocation of this Power of Attorney.



5. General Grant of Power and Authority. Subject to any limitations in this directive, my
   Attorney-in-Fact has the power and authority to do all of the following:

   a. Request, review, and receive any information, verbal or written, regarding my
      child(ren)’s physical or mental health including, but not limited to, medical and hospital

   b. Execute on my behalf any releases or other documents that may be required in order to
      obtain this information;

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   c. Consent to the disclosure of this information; and

   d. Consent to the donation of any of my child(ren)’s organs for medical purposes.

6. HIPAA Release Authority. My Attorney-in-Fact shall be treated as I would be with respect to
   my rights regarding the use and disclosure of my child(ren)’s individually identifiable health
   information or other medical records. This release authority applies to any information
   governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I
   authorize any physician, health care professional, dentist, health plan, hospital, clinic,
   laboratory, pharmacy, or other covered health care provider, any insurance company, and the
   Medical Information Bureau, Inc. or other health care clearinghouse that has provided
   treatment or services to my child, or that has paid for or is seeking payment from me for such
   services, to give, disclose, and release to my agent, without restriction, all of my child’s
   individually identifiable health information and medical records regarding any past, present,
   or future medical or mental health condition, including all information relating to the
   diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol
   abuse. The authority given my Attorney-in-Fact shall supersede any other agreement that I
   may have made with my child(ren)’s health care providers to restrict access to or disclosure
   of my child(ren)’s individually identifiable health information. The authority given my agent
   has no expiration date and shall expire only in the event that I revoke the authority in writing
   and deliver it to my child(ren)’s health care provider.

7. Disability/Incapacitation/Incompetence: This Power of Attorney will continue to be
   effective even if I become disabled, incapacitated, or incompetent.

8. Severability: If any part of this document is held to be invalid, illegal, or unenforceable
   under applicable laws, then the remaining parts of the document shall still remain in full
   force and effect and not be affected by any partial invalidity.

9. Compensation: Attorney-in-Fact shall be entitled to reimbursement of all reasonable
   expenses incurred as a result of carrying out any provision of this Power of Attorney.

By signing here, I indicate that I am fully informed as to the content of this document and
understand the full import of this grant of power to the Attorney-in-Fact named herein.

IN WITNESS WHEREOF, I hereunto set my hands and seals on ____ [Month] ____ [Date],
20____ [Year[.



[Instruction: Insert signature of Parents]


[Instruction: Insert signature of Agent]

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Witness #1: __________________________                    Witness #2:________________________

Name: ______________________________                   Name: ______________________________

Address: ____________________________                  Address: ____________________________

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State of California

County of __________________ [Instruction: Insert county]

I, the undersigned, a Notary Public, in and for said County, in said State, hereby certify that
__________________________ [Instruction: Insert name of principal], whose name is signed
to the foregoing Power of Attorney and who is known to me, acknowledged before me on this
day, that, being fully informed of the contents of the foregoing instrument, he/she executed the
same voluntarily on the day the same bears date.

Given under my hand and official seal this the ________ [Date] day of ________ [Month], ____


                                                       Notary Public

                                                       My commission expires: _______________


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