This Revocation of Power of Attorney is used to revoke a power of attorney for care and custody of children previously executed by a individual. A power of attorney appoints an agent to act on behalf of an principal for some specified purpose, such as to take care of the principal's children. This document effectively revokes the authority granted to the agent and complies with state laws that require the revocation to be in a signed written instrument and delivered to the agent. This should be utilized by a principal located in Kansas to revoke a power of attorney for the care and custody of children.
Docstoc Legal Agreements This Revocation of Power of Attorney is used to revoke a power of attorney for care and custody of children previously executed by a individual. A power of attorney appoints an agent to act on behalf of an principal for some specified purpose, such as to take care of the principal's children. This document effectively revokes the authority granted to the agent and complies with state laws that require the revocation to be in a signed written instrument and delivered to the agent. This should be utilized by a principal located in Kansas to revoke a power of attorney for the care and custody of children. ® DISCLAIMERS: ALL INFORMATION AND FORMS ARE PROVIDED “AS IS” WITHOUT ANY WARRANTY OF ANY KIND, EXPRESS, IMPLIED, OR OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND COMPLETENESS. They are for general guidance and should be modified by you or your attorney to meet your specific needs and the laws of your state. Use at your own risk. 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All Rights Reserved POWER OF ATTORNEY: CARE AND CUSTODY OF CHILD OR CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: 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. 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 © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 2 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 insurance. 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. 4. SPECIFICALLY EXCLUDED FROM THE AUTHORITY AND POWERS GRANTED HEREIN IS THE AUTHORITY OR POWER TO CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN) NAMED HEREIN. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY CHILD(REN)’S PHYSICAL OR MENTAL HEALTH. 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 records; b. Execute on my behalf any releases or other documents that may be required in order to obtain this information; 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 © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 3 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] Witness #1: __________________________ Witness #2:________________________ Name: ______________________________ Name: ______________________________ Address: ____________________________ Address: ____________________________ © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 4 ACKNOWLEDGEMENT State of Kansas 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], ____ [Year]. ____________________________________ Notary Public My commission expires: _______________ (NOTARIAL SEAL) © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 5
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