Fill and Sign the Special Power Child 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 attorney from any requirement of form, substance, formality, or recording that is prescribed for powers of attorney by the laws of a state, the District 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 necessary 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 remain 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 WHEREO F, I have hereunto set my hand and seal on this day, month and year,       . _______________________________________________________ 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 ____ day 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 above 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