Fill and Sign the Fillable Online Staff Application Form July 2018 Kings Kids Nz

2 REVOCATION OF POWER OF ATTORNEY FOR CARE OF A MINOR CHILDAs provided for in T.C.A. § 34-6-301 et seq., revocation of any previously executed Power of Attorney for Care of a Minor Child must be in writing. Properly executed, this form meets all requirements of T.C.A. § 34-6-301 et seq. to properly revoke said Power of Attorney for Care of a Minor Child. Please note, however, that use of this form is recommended, but not required to revoke a previously executed Power of Attorney for Care of a Minor Child.Part I: To be filled out and/or initialed by parent(s).1.Minor Child’s Name 2. Mother/Legal Guardian’s Name & Address 3. Father/Legal Guardian’s Name & Address 4. Caregiver’s Name & Address Part II: To be filled out by the parent(s).I, , hereby revoke the Power of Attorney for are of aName of Parent(s)Minor Child for the child listed above in Part I, which was previously executed on and give to to act as said minor child’s Date Name of CaregiverCaregiver. All rights, power, and authority previously granted to said Caregiver pursuant to said Power of Attorney for Care of a Minor Child are hereby revoked, effective immediately. I understand that I must provide a copy of the Revocation to any health care provider and/or school that previously received a copy of the Power of Attorney. 2 IN WITNESS WHEREOF, I/We sign this Revocation of Power of Attorney for care of a Minor Child and declare under penalty of perjury under the laws of the State of Tennessee that the foregoing is true and correct.STATE OF TENNESSEE )COUNTY OF ) Date: Mother/Legal GuardianThe Mother/Legal Guardian, , personally appearedbefore me this day of , 20 88. ________________________________NOTARY PUBLICMy commission expires:__________________STATE OF TENNESSEE )COUNTY OF ) Date: Father/Legal GuardianThe Father/Legal Guardian, , personally appearedbefore me this day of , 2088.________________________________NOTARY PUBLICMy commission expires:__________________