SPECIAL POWER OF ATTORNEY FOR MEDICAL AUTHORIZATION
I, _____________________, of ___________________, hereby appoint ______________________________  of __________________________, 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 _________ may deem necessary regarding the medical treatment of my children, __________ and/or ____________.

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shall remain in full force and effect until __________________________ or unless specifically extended or rescinded earlier by either party.

Dated _________________________, 20__.

__________________________


STATE OF ___________________  

COUNTY OF __________________ 

BEFORE ME, the undersigned authority, on this __ day of _______________, 20__, personally appeared ______________________ 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.

___________________________
 NOTARY PUBLIC
My Commission Expires:_____