Fillable Printable AOC-796 - Medical Power of Attorney for Minor Child - Kentucky

AOC-796 - Medical Power of Attorney for Minor Child - Kentucky

AOC-796

Rev. 2-08

Page 1 of 1

Commonwealth of Kentucky

Court of Justice

www.courts.ky.gov

KRS 27A.095

STANDARD

POWER OF ATTORNEY FOR

MEDICAL/SCHOOL

DECISION MAKING

KNOW ALL PERSONS BY THESE PRESENTS:

That I, ___________________________________, a resident of __________________(city) ______________(county)

__________(state) residing at ___________________________________(street address) do hereby make, constitute,

and appoint _______________________________, residing at __________________________________________(full

address) my true and lawful attorney in fact for me and in my name, place and stead, in their sole discretion, to transact,

handle and dispose of the limited matters set forth herein, specifically:

To consent to medical treatment for __________________________, minor child, of whom I am the biological parent,

legal custodian or legal guardian. Medical treatment means any medical, chiropractic, optometric, or dental examination,

diagnostic procedure, and treatment, including but not limited to hospitalization, developmental screening, mental health

screening and treatment, preventive care, pharmacy services, immunizations recommended by the federal Centers for

Disease Control and Prevention’s Advisory Committee on Immunization practices, well-child care, and blood testing,

except that “medical treatment” shall not include HIV/AIDS testing, controlled substance testing, or any other testing for

which a separate court order or informed consent is required under other applicable law.

To make school-related decisions for _______________________, minor child, of whom I am the biological parent, legal

custodian or legal guardian. I hereby affirm that the minor child resides with ___________________________________

(attorney in fact) at _____________________________________________________________________ (full address).

This instrument is intended to, and does hereby, grant to my attorney full power and authority to do and perform each and

every act and thing whatsoever requisite, necessary and proper to be done, in the exercise of the rights and powers

herein granted, as fully, to all intents and purposes, as I might or could do personally present, hereby ratifying and

confirming all that my attorney shall do or cause to be done by virtue thereof.

It is fully understood that any school district asked to recognize the authority assigned by this instrument may regularly

review and/or audit the residency of the child. Falsification of this document may constitute a criminal offense.

The rights, powers and authority of my attorney shall commence upon execution of this instrument and shall remain in full

force and effect until this instrument is terminated by me in writing.

So acknowledged this _______ day of ____________________, 2________.

____________________________________ ______________________________________

Parent/Legal Guardian’s Name (printed) Parent/Legal Guardian’s Signature

Subscribed and sworn before me on_______________, 2_______.

__________________________________________, Notary Public. My commission expires: ___________,2_____.

THIS IS NOT A COURT ORDER

The execution or possession of this form does not signify that a person has lawful custody or guardianship of the child

mentioned herein. The limited purpose of this form is to indicate that the above-named person given power of attorney has

the authority to consent to medical treatment and to make school-related decisions for the above-named child. This form is

not required to be filed with the circuit court clerk. Falsification of this document may constitute a criminal offense.