JDF 751 2 / 1 8 DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO 24715 - 14 - 105, C.R.S. DELEGATION OF POWER BY PARENT OR GUARDIAN PURSUANT TO 247 15 - 14 - 105, C.R.S . I, ( f ull name) , parent or guardian of the minor child (ren) or incapacitated person (s) named below: Full Name of Child or Incapacitated Person Date of Birth Relationship I h ereby authorize and appoint (name of person) , as Attorney in Fact for me with full authority to act in my place as follows: 1. To perform any and all acts necessary for the day - to - day care, custody, education, recreation, and property of the above - named mino r child or incapacitated person, consistent with the provision of 247 15 - 14 - 105, C.R.S. 2. T o authorize any and all medical and dental care for the health and well being of the minor child(ren) or incapacitated person(s). This care includes, but is not limited to medical and dental exams and test s , x - rays, surgeries, anesthesia, and hospital care. This Special Power of Attorney does not give the Attorney in Fact the power to consent to the marriage or adoption of the child or incapacitated person. This Special Power of Attorney shall be effective until u nless r evoked earlier by the parent or guardian in writing . In any case, the authority granted herein shall not be valid for more than 12 months from the date of this document. Date: Parent /Guardian Signature Subscribed and affirmed, or sworn to before me in the County of , State of , this day of , 20 . My Commission Expires: Notary Public /Clerk American LegalNet, Inc. www.FormsWorkFlow.com