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Commonwealth of Kentucky
Court of Justice
POWER OF ATTORNEY FOR
KNOW ALL PERSONS BY THESE PRESENTS:
That I, ___________________________________, a resident of __________________(city) ______________(county)
__________(state) residing at ___________________________________(street address) do hereby make, constitute,
and appoint _______________________________, residing at __________________________________________(full
address) my true and lawful attorney in fact for me and in my name, place and stead, in their sole discretion, to transact,
handle and dispose of the limited matters set forth herein, specifically:
To consent to medical treatment for __________________________, minor child, of whom I am the biological parent,
legal custodian or legal guardian. Medical treatment means any medical, chiropractic, optometric, or dental examination,
diagnostic procedure, and treatment, including but not limited to hospitalization, developmental screening, mental health
screening and treatment, preventive care, pharmacy services, immunizations recommended by the federal Centers for
Disease Control and Prevention’s Advisory Committee on Immunization practices, well-child care, and blood testing,
except that “medical treatment” shall not include HIV/AIDS testing, controlled substance testing, or any other testing for
which a separate court order or informed consent is required under other applicable law.
To make school-related decisions for _______________________, minor child, of whom I am the biological parent, legal
custodian or legal guardian. I hereby affirm that the minor child resides with ___________________________________
(attorney in fact) at _____________________________________________________________________ (full address).
This instrument is intended to, and does hereby, grant to my attorney full power and authority to do and perform each and
every act and thing whatsoever requisite, necessary and proper to be done, in the exercise of the rights and powers
herein granted, as fully, to all intents and purposes, as I might or could do personally present, hereby ratifying and
confirming all that my attorney shall do or cause to be done by virtue thereof.
It is fully understood that any school district asked to recognize the authority assigned by this instrument may regularly
review and/or audit the residency of the child. Falsification of this document may constitute a criminal offense.
The rights, powers and authority of my attorney shall commence upon execution of this instrument and shall remain in full
force and effect until this instrument is terminated by me in writing.
So acknowledged this _______ day of ____________________, 2________.
Parent/Legal Guardian’s Name (printed) Parent/Legal Guardian’s Signature
Subscribed and sworn before me on_______________, 2_______.
__________________________________________, Notary Public. My commission expires: ___________,2_____.
THIS IS NOT A COURT ORDER
The execution or possession of this form does not signify that a person has lawful custody or guardianship of the child
mentioned herein. The limited purpose of this form is to indicate that the above-named person given power of attorney has
the authority to consent to medical treatment and to make school-related decisions for the above-named child. This form is
not required to be filed with the circuit court clerk. Falsification of this document may constitute a criminal offense.