SPECIAL POWER OF ATTORNEY PURSUANT TO §15-14-105, C.R.S. I, __________________________________________ (full name), legal resident of Colorado and lawful parent or guardian of the minor child(ren) or incapacitated person(s) named below: Full Name of Child Incapacitated Person or Date of Birth Relationship I hereby authorize and appoint __________________________________ (name of person), _____________________ (date of birth) 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 minor child(ren) or incapacitated person(s), consistent with the provision of §15-14-105, C.R.S. 2. To 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 tests, x-rays, surgeries, anesthesia, and hospital care. Any medical treatment shall be provided only upon the advice and supervision of a licensed surgeon, physician, dentist, or other medical practitioner. This Special Power of Attorney shall be effective from ____________________ to ____________________ (time period) unless revoked earlier by the parent or guardian. In any case, the Special Power of Attorney period shall not exceed 12 months. 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: ______________ JDF 52 10/06 ______________________________________ Notary Public/Clerk SPECIAL POWER OF ATTORNEY PURSUANT TO §15-14-105, C.R.S. American LegalNet, Inc. www.FormsWorkflow.com