Fill and Sign the Delegation Parent Form

DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO § 15-14-105, C.R.S . I, __________________________________________ (full name), parent or guardian of the minor child(ren) or incapacitated person(s) named below: Full Name of Child or Incapacitated Person Date of Birth Relationship ______________________________ ________________ ________________ I hereby authorize and appoint __________________________________________ (name of person), as Attorney in Fact for me with full authority to act in my place as follows: 1. To perform any and all acts necessary for the day-to-day care, custody, education, recreation, and property of the above-named minor child or incapacitated person, consistent with the provision of §15-14-105, C.R.S. 2. To authorize any and all medical and dental care for the health and well being of the minor child(ren) or incapacitated person(s). This care includes, but is not limited to medical and dental exams and tests, x-rays, surgeries, anesthesia, and hospital care. This Special Power of Attorney does not give the Attorney in Fact the power to consent to the marriage or adoption of the child or incapacitated person. This Special Power of Attorney shall be effective until ________________ unless revoked earlier by the parent or guardian in writing. In any case, the authority granted herein shall not be valid for more than 12 months from the date of this document. Date: _______________________ _________________________________________ Parent/Guardian Signature Subscribed and affirmed, or sworn to before me in the County of ________________ , State of ________________ , this ________________ day of ________________ , 20 ________________ . My Commission Expires: ______________ ______________________________________ Notary Public/Clerk DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO §15-14-105, C.R.S.