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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rescinded earlier by either party.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 he executed 

the same freely and voluntarily for the uses and purposes therein expressed.  



	WITNESS my hand and official seal the date aforesaid.  



                                  __________(18)_________________

                                                 NOTARY PUBLIC



                                 My Commission Expires:__(19)___ 





NOTICE



	The information in this document is designed to provide an outline that you can follow 

when formulating business or personal plans.  Due to the variances of many local, city, county 

and state laws, we recommend that you seek professional legal counseling before entering into 

any contract or agreement.