Fill and Sign the Georgia General Form

POWER OF ATTORNEY: CARE AND CUSTODY OF CHILD OR CHILDREN KNOW ALL MEN BY THESE PRESENTS: That the undersigned, _____________________________________________________ , parent(s) of the child(ren) identified below, residing at _____________________________________________ hereby make, constitute and appoint _____________________________________________ (if more than one attorney-in-fact is appointed, add 'Jointly," "either of them" or "any one of them" to indicate how they must act) as the true and lawful Attorney(s)-in-Fact of the undersigned, to act in name, place and stead of the undersigned, to do and execute all or any of the following acts, deeds and things with respect to the care and custody of the following child(ren): __________________________________________________________________ __________________________________________________________________ (a) To participate in decisions regarding the child(ren)’s education including attending conferences with the child(ren)’s teachers or any other educational authorities, granting permission for the child(ren)’s participation in school trips and other activities, and making any other decisions and executing any documents pertinent to their education. (b) To grant permission and consent to the child(ren) participating in any activity sponsored by any group, association or organization which activity the Attorney(s)-in-Fact may deem appropriate. (c) To make health care decisions on behalf of the child(ren), including making decisions regarding the child(ren)’s 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 the child(ren) and to examine the child(ren)’s medical records and to consent to the disclosure of such records in circumstances the Attorney (s)-in- fact may deem appropriate; to file claims for medical insurance and to obtain information Power of Attorney Page 1 of 3 from any insurance company with respect to any policy of health or medical insurance under which the child(ren) may be insured; provided however, that the Attorney(s)-in-Fact shall not be required to execute any documents which would involve incurring any personal liability for any such treatment and care, and the undersigned affirms that the undersigned will be responsible for payment for any such care or treatment consented to by the Attorney(s)-in-Fact of the undersigned which is not covered by insurance. (d) To generally do and perform all matters and things, to execute all other instruments of every kind which may be necessary or proper to effectuate all powers hereinabove specifically granted, or any other matter or thing appertaining to the child(ren) of the undersigned, with the same full powers, and to all intents and purposes, with the same validity as the undersigned could, if personally present; and hereby ratifying and confirming whatsoever said Attorney (s)-in-fact of the undersigned shall and may do, by virtue hereto. (e) 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. (f) Except as may be permitted by the federal No Child Left Behind Act, 20 U.S.C.A. Section 6301, et seq. And Section 7801, et seq., I hereby certify that this power of is not executed for the primary purpose of unlawfully enrolling the child in a school so that the child may participate in the academic or interscholastic athletic programs provided by that school. (g) I certify that the minor child is not emancipated and, if the minor child becomes emancipated, this power of attorney shall no longer be valid. (h) The powers herein granted to said Attorney(s)-in-Fact of the undersigned shall be exercisable by any one of them or all of them at any time and from time to time from _______________________ until _______________________ but not for a period that exceeds one (1) year. Power of Attorney Page 2 of 3 (i) This Power of Attorney shall remain in full force and effect until the date stated above, and any party dealing with the Attorney (s)-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. I declare under penalty of perjury under the laws of the State of Georgia that the foregoing is true and correct. Dated:______________, 20____. Signed, sealed and delivered in presence of: Unofficial Witness Principal Signature __________________________________ Notary Public Print or Type Name My Commission expires: [NOTARIAL SEAL] Power of Attorney Page 3 of 3