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brain dead if there is a chance that doing so might allow my child to be born alive. Except as I
specify by writing my signature in the box below, no one is authorized to consent to any
procedure for me that would result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal condition as defined above,
medical procedures required to prevent my death are authorized even if they may result in the
death of my unborn child provided every possible effort is made to preserve both my life and the
life of my unborn child.
Signature of Declarant
Signed this ____________________day of ___________________________, 20_______.
Date of Birth or Social Security Number
The principal voluntarily signed this writing in my presence.
First Witness Signature:__________________________________________________________
Second Witness Signature:________________________________________________________
form prepared 2001
*clerical changes made 11/05