Fillable Printable Health Care Power of Attorney over Minor Child - Arizona

Health Care Power of Attorney over Minor Child - Arizona

POWER OF ATTORNEY OVER A

MINOR CHILD – HEALTH CARE

FORMS AND INSTRUCTIO NS

INSTRUCTIONS

A power of attorney over a child is a document signed and notarized by a parent giving a non-

parent authority to make decisions for a minor child. It is not a court order. It is accepted by

many, but not all, people or organizations as authority over the child. It is typically used by a

parent who is unavailable for a period of time and wants to grant authority to another person over

their child. It can be used to authorize the person to obtain medical treatment for a child or sign

up a child for an activity or for other significant decisions. You can also limit the purpose to

something very specific (for example, to take a child on vacation, to authorize specific medical

treatment, etc.).

A power of attorney over a minor child is effective for a maximum of six months. You can limit

this time period to as little as you want, but you cannot extend it beyond six months. If you need

another power of attorney after six months, simply sign a new power of attorney. A better idea,

however, may be to obtain a guardianship agreed to by all parties.

A parent who does not agree with this power of attorney has more authority over the child than

the person with the power of attorney.

In paragraph 3, the parent must indicate what powers he or she is giving over the minor child.

The first box is for a general power of attorney granting all powers a parent would ordinarily

have over the child. If the parent wants to limit the powers to certain areas, they should check the

second box and describe the specific powers granted.

The parent must sign the completed power of attorney in front of a notary public and another

witness. The witness must also sign. Notarize two copies of the power of attorney; one is for the

person with the power and the other for the parent granting the power. Make several copies of

the power of attorney since you will probably have to give a copy to each person or organization

that you need to deal with on behalf of the child. Show them the original, and give them the

copy. Keep the original in a safe place.

The parent granting the power of attorney can withdraw (revoke) that power at any time, even

before the expiration date on the power of attorney. It is best that the withdrawal be in writing. A

form called Revocation of Power of Attorney is attached. If you are a parent withdrawing the

power, be sure to fill out the revocation form and deliver it to the person to whom you granted

the power. The withdrawal is effective immediately upon delivery.

POWER OF ATTORNEY OVER A MINOR CHILD – HEALTH CARE

STATE OF ARIZONA )

) ss

County of Maricopa )

I, _____________________ of:

Parent/Guardian Name

______________________

Address

______________________

City State Zip Code

do solemnly swear that:

1. I am the natural parent of

Name of Child(ren) Date of Birth

2. I authorize

____________________________

Name of person authorized

____________________________

Address

____________________________

City State Zip Code

to assume power of attorney over my minor children, in accordance with the

provisions of Arizona Revised Statutes, Section 14-5104, which states as follows:

A parent or guardian of a minor or incapacitated person, by properly

executed power of attorney, may delegate to another person, for a period

not exceeding six months, any powers he may have regarding care,

custody or property of the minor child or ward, except power to consent to

marriage or adoption of the minor.

3. I further appoint____________________ as my true and lawful attorney-in-fact,

Name of Person Authori zed

for me and in my name, place and stead, for the purpose of giving or refusing

consent to any medical treatment, including x-ray examination, anesthetic, medical

or surgical diagnosis and treatment, hospital admission, or other related health care

needs; to obtain medical and dental tr eatment, whether an e mergency or not, and to

consent and give permission for any operations, treatment or health care. Such

attorney-in-fact is authorized to sign any and all forms required by health care

agencies to indicate parental permission on behalf of each child.

4. This Power of Attorney will begin on ______________ and expire on

_________________ unless I revoke it earlier. Date

No more then 6 months

5. I have given this consent of my own free will.

6. A photocopy or other reproduction of this power of attorney may be relied upon

to the same extent as a signed original.

Witness signature Signature of parent granting power of

attorney

SUBSCRIBED and SWORN to before to on this date:

Notary Public

My Commission Expires:

REVOCATION OF POWER OF ATTORNEY

I, _____________, hereby revoke (withdraw) the power of attorney over my minor child(ren) I

granted _______________ to on the following date: _______________. That power of attorney

is now null and void.

Today’s date: ___________________

Signature of parent who granted original power