I, ______________________________, of ____________________________, Oregon,

being the natural mother/father of the child/ren below named, have temporarily appointed, and by

this document do temporarily appoint _________________________________, of

________________________________, Oregon, my true and lawful attorney, for me and in my name

and place, and for my benefit:

1. To have the care, custody and control of my child/ren:

Name: __________________________ Date of Birth: ____________________

Name: __________________________ Date of Birth: ____________________

Name: __________________________ Date of Birth: ____________________

Name: __________________________ Date of Birth: ____________________

and do all things necessary to properly care for my said child/ren:

2. To consent to and authorize any and all medical treatment necessary for the properly care and well-being for my child/ren.

3. To consent to and authorize any and all actions necessary for the proper care of my child/ren as regards to her/his/their attendance at any public or private institution or school.

I HEREBY GRANT my said attorney full power and authority freely to do every act necessary to be done, as fully to all intents and purposes, as I might or could do if personally present, and I hereby ratify and confirm that which my said attorney-in-fact shall lawfully do or cause to be done by virtue of this document.

(Initial one)

A. _____ This Temporary Power of Attorney is valid for six (6) months from the date on which I have signed it, unless earlier revoked by me.

B. _____ This Temporary Power of Attorney is valid until ________________, 2____. (Must be less than six (6) months from date of signing)

IN WITNESS WHEREOF, I have signed this Temporary Power of Attorney on this _____ day of _____________, 2____.

 

___________________________________________

STATE OF OREGON )

) ss

County of __________ )

 

SUBSCRIBED AND SWORN TO before me this ____ day of ___________, 2______.

 

__________________________________________

Notary Public for Oregon

My Commission Expires: __________