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SPECIAL POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION
I, (1), of (2), hereby appoint (3) of (4), as my attorney in fact to act in my capacity to do any and all of the following:
1. Make any and all decisions and authorize all procedures that (5)____ may deem necessary regarding the medical treatment of my children, (6) and/or (7).
The rights, powers, and authority of my attorney in fact to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect and shall remain in full force and effect until (8) or unless specifically extended or rescinded earlier by either party.
Dated (9), 19_(10)_.
(11)
STATE OF (12)
COUNTY OF (13)
BEFORE ME, the undersigned authority, on this _(14)_ day of (15), 19_(16)_, personally appeared (17) to me well known to be the person described in and who signed the Foregoing, and acknowledged to me that
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