Fillable Printable Power of Attorney for Guardianship of Children - Tennessee

Power of Attorney for Guardianship of Children - Tennessee

Tennessee Power of Attorney for Minor Child

POWER OF ATTORNEY FOR CARE OF A MINOR CHILD

Use of this form is authorized by T.C.A. § 34-6-301 et seq. Completion of this form,

along with the proper signatures, is sufficient to authorize enrollment of a minor in school

and to authorize medical treatment. However, a school district may require additional

documentation/information as permitted by this section of Tennessee law before enrolling

a child in school or any extracurricular activities. Please print clearly.

This Power of Attorney is limited in nature and only grants such powers upon the

happening of a specified event.

Part I: To be filled out and/or initialed by parent(s).

1. Minor Child’s Name ________________________________________________

2. Mother/Legal Guardian’s Name & Address ______________________________

______________________________

3. Father/Legal Guardian’s Name & Address ______________________________

______________________________

4. Caregiver’s Name & Address

___________________________________________________________

______________________________

5. (____) Both parents are living, have legal custody of the minor child and have

signed this document;

(____) One parent is deceased;

(____) One parent has legal custody of the minor child and both parents have

signed this document and consent to the appointm ent of the caregiver;

(____) One parent has legal custody of the minor child, and has sent by Certified

Mail, Return Receipt requested, to the other parent at last known address,

a copy of this document and a notice of the provisions in § 34-6-305; or

the non-custodial parent has not consented to the appointment and consent

cannot be obtained because ______________________________.

Tennessee Power of Attorney for Minor Child

6. Temporary care-giving authority regarding the minor child is being given to the

caregiver ONLY upon the occurrence of (check at least one):

(____) a serious illness or incarceration of a parent or legal guardian;

(____) the detention or removal or deportation of a parent or legal guardian;

(____) the loss or uninhabitability of the child’s home as a result of a natural

disaster;

(____) the need for medical or mental health treatment (including substance abuse

treatment) by the parent or legal guardian;

(____) or a physical or mental condition of the parent or legal guardian or the

child is such that care and supervision of the child cannot be provided;

(____) other (please describe) _________________________________________

___________________________________________________________.

7. I/We the undersigned, authorize the named caregiver to do one or more of

the following:

(_____) enroll the child in school and extracurricular activities (including

but not limited to Boy Scouts, Boys & Girls Club),

(_____) obtain medical, dental, and mental health treatment for the child,

and

(_____) provide for the child’s food, lodging, housing, recreation and

travel.

(_____) I/We grant the following additional power to the named caregiver:

______________________________________________________

______________________________________________________.

8. (____) I/We understand that this document does not provide legal custody to the

caregiver. If at any time I/we disagree with a decision of the named

caregiver or choose to make any healthcare or educational decisions for

my/our child, I/we must revoke the power of attorney, in writing, and

provide written documentation to the health care provider and the local

education agency (i.e., school).

9. (____) I/We understand that this document may be terminated in another

written document signed by either parent with legal custody or by any

order of a court with competent jurisdiction.

Tennessee Power of Attorney for Minor Child

Part II: To be initialed by caregiver.

10. (____) I understand that this document, properly executed, gives me the right to

enroll the minor child in the local education agency serving the area where

I reside.

11. (____) I understand that this document does not provide me with legal custody.

12. (____) I understand that, prior to enrollment, the local education agency may

require documentation of the minor child’s residence with a caregiver

and/or documentation or other verification of the validity of the stated

hardship.

13. (____) I understand that, except where limited by federal law, I shall be assigned

the rights, duties, and responsibilities that would otherwise be assigned to

the parent, legal guardian or legal custodian pursuant to Tennessee Code

Annotated Title 49.

14. (____) I understand that, if the minor child ceases to reside with me, I am

required by law to notify any person, school or health care provider to

whom I have given this document.

Part III: To be initialed by parent(s) and caregiver.

15. (____) (____) We understand that, by accepting the power of attorney, if we

enroll a student in a school system while fraudulently representing

the child’s current residence or the parents’ hardship or

circumstances for using the power of attorney, either or both of us

is liable for restitution to the school district for an amount equal to

the per pupil expenditure for the district in which the student is

fraudulently enrolled. Restitution shall be cumulative for each year

the child has been fraudulently enrolled in the system and may

include costs and fees related to litigation.

________________________________________________________________________

I/We declare under penalty of perjury under the laws of the State of Tennessee that the

foregoing is true and correct.

STATE OF TENNESSEE)

COUNTY OF __________ )

______________________________ Date: ______________

Mother/Legal Guardian

The Mother/Legal Guardian, ______________________, personally appeared

Tennessee Power of Attorney for Minor Child

before me this _____ day of ____________, 20___.

______________________________

NOTARY PUBLIC

My commission expires:

___________________

STATE OF TENNESSEE)

COUNTY OF __________ )

______________________________ Date: ______________

Father/Legal Guardian

The Father/Legal Guardian, ______________________, personally appeared

before me this _____ day of ____________, 20___.

______________________________

NOTARY PUBLIC

My commission expires:

STATE OF TENNESSEE )

COUNTY OF __________ )

______________________________ Date: ______________

Caregiver

The Caregiver, ______________________, personally appeared before me this

_____ day of ____________, 20__.

______________________________

NOTARY PUBLIC

My commission expires:

Tennessee Power of Attorney for Minor Child

NOTICE TO THE LOCAL EDUCATION AGENCY AND/OR HEALTH CARE

PROVIDER:

Pursuant to T.C.A. § 34-6-308, no person, school official or health care provider who acts

in good faith reliance on a power of attorney for care of a minor child to enroll the child

in school or to provide medical, dental or mental health care, without actual knowledge of

facts contrary to those authorized, is subject to criminal or civil liability to any person, or

is subject to professional disciplinary action for such reliance. This section shall apply

even if medical, dental, or mental health care is provided to a minor child or the child is

enrolled in a school in contravention of the wishes of the parent with legal custody of the

minor child, as long as the person, school official or health care provider has been

provided a copy of an appropriately executed power of attorney for care of a minor child,

and has not been provided written documentation that the parent has revoked the power

of attorney for care of a minor child.

Additionally, pursuant to T.C.A. § 34-6-310, a person who relies on the power of

attorney for care of a minor child has no obligation to make any further inquiry or

investigation. Nothing in this part shall relieve any individu al from liability f o r violations

of other provisions of law.