KNOW ALL PERSONS BY THESE PRESENTS:That I, , a resident of (city) (county) (state) residing at (street address) do hereby make, constitute,and appoint , residing at (full address)my true and lawful attorney in fact for me and in my name, place and stead, in their sole discretion, to transact, handle andTo consent to medical treatment for , minor child, of whom I am the biological parent,legal custodian or legal guardian. Medical treatment means any medical, chiropractic, optometric, or dental examination,diagnostic procedure, and treatment, including but not limited to hospitalization, developmental screening, mental healthscreening and treatment, preventive care, pharmacy services, immunizations recommended by the federal Centers forDisease Control and Prevention222s Advisory Committee on Immunization Practices, well-child care, and blood testing,except that 223medical treatment224 shall not include HIV/AIDS testing, controlled substance testing, or any other testing forwhich a separate court order or informed consent is required under other applicable law. To make school-related decisions for , minor child, of whom I am the biological parent, legal(attorney in fact) at (full address).This instrument is intended to, and does hereby, grant to my attorney full power and authority to do and perform each andevery act and thing whatsoever requisite, necessary and proper to be done, in the exercise of the rights and powers hereinthat my attorney shall do or cause to be done by virtue thereof.It is fully understood that any school district asked to recognize the authority assigned by this instrument may regularlyThe rights, powers and authority of my attorney shall commence upon execution of this instrument and shall remain in fullforce and effect until this instrument is terminated by me in writing. So acknowledged this day of , 2. � Parent/Legal Guardian222s Name (printed) � Parent/Legal Guardian222s Signature AOC-796Rev. 10-17Page 1 of 1Commonwealth of KentuckyCourt of Justice www.courts.ky.govKRS 27A.095STANDARD POWER OF ATTORNEY FOR MEDICAL/SCHOOL DECISION MAKING lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE THIS IS NOT A COURT ORDER.The execution or possession of this form does not signify that a person has lawful custody or guardianship of the child mentioned herein. The limited purpose of this form is to indicate that the above-named person given power of attorney has the authority to consent to medical treatment and to make school-related decisions for the above-named child. This form is Subscribed and sworn before me on , 2. American LegalNet, Inc. www.FormsWorkFlow.com