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Oregon Parental Guardianship Power of Attorney Form

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Oregon Parental Guardianship Power of Attorney Form Page 2
Oregon Parental Guardianship Power of Attorney Form
DELEGATION OF PARENTAL/GUARDIAN POWERS
I certify that I am the parent or legal guardian of:
_____________________________________ ___________________________
(
FULL NAME OF MINOR CHILD)(DATE OF BIRTH)
_____________________________________ ___________________________
(FULL NAME OF MINOR CHILD)(DATE OF BIRTH)
_____________________________________ ___________________________
(FULL NAME OF MINOR CHILD)(DATE OF BIRTH)
(“minor child/ren”). I designate ___________________________________________________,
(FULL NAME OF ATTORNEY-IN-FACT)
_____________________________________________________________________________,
(STREET ADDRESS, CITY, STATE AND ZIP CODE OF ATTORNEY-IN-FACT)
_________________________________ _________________________________
(HOME PHONE OF ATTORNEY-IN-FACT) (WORK PHONE OF ATTORNEY-IN-FACT)
as the undersigned’s attorney-in-fact with respect to the minor child/ren under ORS 109.056.
I delegate to the attorney-in-fact all of my power and authority regarding the care,
custody and property of the minor child/ren, including but not limited to the right to enroll the
minor child/ren in school, inspect and obtain copies of education records and other records
concerning the minor child/ren, the right to attend school activities and other functions
concerning the minor child/ren, and the right to give or withhold any consent or waiver with
respect to school activities, medical and dental treatment, and any other activity, function or
treatment that may concern the minor child/ren. OR
I delegate to the attorney-in-fact the following specific powers and responsibilities
(write in):
Page 1 of 2, DELEGATION OF PARENTAL/GUARDIAN POWERS
POA Form Instructions 1P-15Ver01.wpd (12-04)
Oregon Parental Guardianship Power of Attorney Form