Free SPECIAL POWER OF ATTORNEY PURSUANT TO 1973, C - Colorado

DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO §15-14-105, C.R.S.

I, __________________________________________ (full name), parent or guardian of the minor child(ren) or incapacitated person(s) named below:

Full Name of Child Incapacitated Person

or Date of Birth

Relationship

I hereby authorize and appoint __________________________________ (name of person), as Attorney in Fact for me with full authority to act in my place as follows:

1. To perform any and all acts necessary for the day-to-day care, custody, education, recreation, and property of the above-named minor child or incapacitated person, consistent with the provision of §15-14-105, C.R.S.

2. To authorize any and all medical and dental care for the health and well being of the minor child(ren) or incapacitated person(s). This care includes, but is not limited to medical and dental exams and tests, x-rays, surgeries, anesthesia, and hospital care.

This Special Power of Attorney does not give the Attorney in Fact the power to consent to the marriage or adoption of the child or incapacitated person.

This Special Power of Attorney shall be effective until ____________________ unless revoked earlier by the parent or guardian in writing. In any case, the authority granted herein shall not be valid for more than 12 months from the date of this document.

Date: _______________________

_________________________________________ Parent/Guardian Signature

Subscribed and affirmed, or sworn to before me in the County of _____________________________, State of ________________, this ___________ day of _______________, 20 ______.

My Commission Expires: ______________

______________________________________ Notary Public/Clerk

JDF 751 3/08 DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO §15-14-105, C.R.S.