1. Make any and all decisions and authorize all procedures that _____(5)____ may deem necessary regarding the medical treatment of my children, _____(6)_____ and/or ______(7)______.

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effect and shall remain in full force and effect until ___________(8)_______________ or unless specifically extended or rescinded earlier by either party.

Dated ___________(9)______________, 19_(10)_.

____________(11)______________

STATE OF _______(12)____________

COUNTY OF ______(13)____________

BEFORE ME, the undersigned authority, on this _(14)_ day of _______(15)________, 19_(16)_, personally appeared ___________(17)___________ 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.

__________(18)_________________

NOTARY PUBLIC

My Commission Expires:__(19)___