3100 West River Parkway
Minneapolis, MN 55406
NON-DURABLE POWER OF ATTORNEY FOR PHYSICAL
AND HEALTH CARE OF MINOR CHILD
THE POWERS YOU GRANT BELOW WILL TERMINATE IF YOU BECOME
DISABLED OR INCOMPETENT
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROUD AND SWEEPING. THEY
ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT. IF YOU
HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. YOU
MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
POWER OF ATTORNEY made this day of , .
I, , residing
as the sole custodial parent of [Child Name]
(insert the name and address of the person appointed)
as my attorney-in-fact (my “agent”) to act for and in my name (in any way I could act in person) to provide
for the temporary care of my child and to make any and all decisions for me concerning my child,
(child’s name) in regards to his personal care, medical treatment,
hospitalization and health care to require, withhold or withdraw any type of medical treatment or
procedure, even though my child’s death may ensue. My agent shall make every effort to prolong to the
greatest extent possible, the chances of my child to recover without regard to my child’s condition or the
costs of procedures until such time as I can be contacted and provide directions regarding life-support, food
My agent shall have the same access to my child’s medical records that I have, including the right to disclose
the contents to others.
The powers granted above shall not include the following powers or shall be subject to the following rules
My agent shall not have the power or authority to authorize the termination of life-support, food or
This power of attorney shall become effective on the day of , . While this power
of attorney is in effect, I will be
, and can be
located by .
This power of attorney shall terminate as soon as I resume the physical care of my child or as soon as I
direct medical care personnel or other authorities of the termination of this power of attorney.
If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be
unavailable, I name the following (each to act alone and successively, in the order named) as successors to