Fill and Sign the Possession of the United States Form

SPECIAL POWER OF ATTORNEY (CHILD MEDICAL) PREAMBLE: This is a MILITARY POWER OF ATTORNEY prepared pursuant to Title 10, United States Code, § 1044b , and executed by a person authorized to receive legal assistance from the military services. Federal law exempts this power of at torney from any requirement of form, substance, formality, or recording that is prescribed for powers of attorney by the laws of a state, the Distri ct of Columbia, or a territory, commonwealth, or possession of the United States. Federal law specifies that this power of attorney shall be given the same legal effect as a power of attorney prepared and executed in accordance with the laws of the jurisdiction where it is presented. KNOW ALL PERSONS: That I, _________________________________, currently residing at ___________________________________________ by this document do make and appoint _____________________________, whose address is __________________________________________ __ as my true and lawful attorney-in-fact to act as follows, GRANTING unto my said Attorney full power to: Authorize and execute consent for any and all medical and hospital care and treatment, including major surgery, deemed necessar y by a duly licensed physician selected by my Attorney-in-Fact for the health and well-being of my following child(ren): Name: _____________________________________ DOB: _____________________ Name: _____________________________________ DOB: _____________________ Name: _____________________________________ DOB: _____________________ Name: _____________________________________ DOB: _____________________ Name: _____________________________________ DOB: _____________________ TERMINATION: This power shall remain in full force and effect until _____________________, unless sooner revoked or terminated by me. Notwithstanding my insertion of a specific expiration date herein, if on the above specified expiration date I shall be, or have been, carried in a military status of “missing”, “missing-in-action” or “prisoner of war,” then this power of attorney shall automatically re main valid and in full effect until sixty (60) days after I have returned to the United States Military control following termination of such status . This power of attorney shall not be affected by the disability of the principal. IN WITNESS WHEREOF , I have hereunto set my hand and seal on this day, ____________________. _____________________________________Grantor’s Signature WITNESSED: PRINT NAME: PRINT NAME: PRINT ADDRESS PRINT ADDRESS: _________________________________________________________________________________________________________________________ ACKNOWLEDGEMENT BY NOTARY PUBLIC _________________________________________________________________________________________________________________________ STATE OF ________________________, COUNTY OF _______________________, ss. The foregoing instrument was acknowledged before me by _________________________and the above named two witnesses, this ____ da y of ____________________, _______. ________________________________ Print Name: Notary Public _________________________________________________________________________________________________________________________ ACKNOWLEDGEMENT BY A PERSON AUTHORIZED TO ACT AS A NOTARY PURSUANT TO TITLE 10 U.S.C. 1044a _________________________________________________________________________________________________________________________ With the United States Armed Forces At ____________________________, the forgoing instrument was acknowledged before me by ______________________________ and the a bove named two witnesses, this ____day of ________________, _______. I do further certify that I am a person in the service of the U.S. Armed Forces authorized the general powers of a notary public under Title 10 U.S.C. 1044a and JAGMAN Chapter IX. __________________________________ __________________________________Print Name, Grade, Armed Force NO SEAL REQUIRED