Provide Your Information


Name:Also known as:
Address:
City:    County:
State: Zip:
Phone Number:
Alternate Number:
Email:
Date of Birth:
Social Security Number:

Provide Your Agent's Information (An agent is the person who will have care of your children)

Name:Also known as:
Address:
City:    County:
State: Zip:


Provide Your Alternate Agent's Information

Name:Also known as:
Address:
City:    County:
State: Zip:


Indicate which powers you want to grant to your Agent:

- To give parental consent to any medical, diagnostic, or surgical procedure and/or treatment
- To give parental consent to any dental procedure
- To give parental consent to admission to any hospital or medical center 
- To give parental consent to the use of any drugs, medication, therapeutic devices, or other medicines or items related to the child’s health 
- To apply to any governmental agency for benefits or government obligations
- To engage in any administrative or legal proceeding or in any litigation in connection with any matter
- The power to take and authorize all acts with respect to your child’s education, the same as you could do 
- The power in general to take and authorize all acts with respect to your child’s health and well-being, the same as you could do 

Indicate any limitations on powers granted to your agent:

Is parent serving in the Armed Forces:Select OneYesNo

If yes, is the parent deployed to a foreign nation: Select OneYesNo

If yes, does the parent wish for the agent to serve until the end of the deployment: Select OneYesNo

Commencement Date of Power:

End Date of Power:


 ACKNOWLEDGMENT: Speedy Legal Docs did not provide me with any advice, explanation or representation about any legal rights, remedies, defenses or options.