STATE OF OREGON )
)
ss
County of
)
I/we are the
parent(s) of _____________________________________,
born___________________ ,
a minor child. I/we give to:
____________________________________________________________
the full authority to act in my/our place regarding any matter concerning the care,
custody, or property of this child, including, but not limited to: granting of consent
for any medical, dental, psychological, psychiatric examinations, care, or treatment
including vaccinations or immunizations; enrollment in school and participation
in school activities; applying for public benefits; and any other matter regarding
the health or welfare of this child except:
________________________________________________________
_________________________________________________________.
This power of
attorney shall be valid for a period ending ___________________
but in no case for
more than 180 days.
I/we reserve the right to terminate (end) this authority at any time.
Signed: ______________________________________________________________
SIGNED AND SWORN
TO before me on this ______________________
day of ______________________, 20_____,
by ___________________________________________________ .
___________________________________________________
Signature of Notary
My Commission Expires: _______________