KRS 403.353: Form of power of attorney authorized by this section, KRS 403.352, and

KRS Chapter 403A.

(1) A power of attorney established pursuant to this section, KRS 403.352, and KRS

Chapter 403A shall be substantially in the following form, and may i nclude other

specific directions which are in accordance with accepted legal practice and not

specifically prohibited by any other statute. If any other specific directions are held

by a court of appropriate jurisdiction to be invalid, that invalidity shall not affect the

power of attorney or other provisions established in this section, KRS 403.352, and

KRS Chapter 403A.

"Power of Attorney for Temporary Delegation

of Parental or Legal Custody and Care

1. I certify that I am the parent or legal guardian of:

__________________________________________ _______________

(Full name of minor child) (Date of birth)

__________________________________________ _______________

(Full name of minor child) (Date of birth)

__________________________________________ _______________

(Full name of minor child) (Date of birth)

2. I designate __________________________ (Full name of Attorney-in-fact),

_______________________________________________________________________

(Street address, city, state, and zip code of Attorney-in-fact)

_______________________________________________________________________

(Home phone of Attorney-in-fact)____________________________________________

(Work phone of Attorney-in-fact)____________________________________________

as the Attorney-in-fact of each minor child named above.

3. I delegate to the Attorney -in-fact all of my power and authority regarding the care,

custody, and property of each minor child named above, including but not limi ted to the

right to enroll the child in school, inspect and obtain copies of education records and

other records concerning the child, the right to attend school activities and other functions

concerning the child, and the right to give or withhold any con sent or waiver with respect

to school activities, medical and dental treatment, and any other activity, function, or

treatment that may concern the child. This delegation shall not include the power or

authority to consent to marriage or adoption of the ch ild, the performance or inducement

of an abortion on or for the child, or the termination of parental rights to the child.

OR

In the event that Section 4 is completed, Section 3 does not apply.

4. I delegate to the Attorney -in-fact the following specific p owers and responsibilities

(write in):

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

This delegation shall not include the power or authority to consent to marriage or

adoption of the child, the performance or inducement of an abortion on or for the child, or

the termination of parental rights to the child.

5. This power of attorney is effective for a period not to exceed one (1) year,

beginning _____________________, 20___,

and ending _____________________, 20__.

I reserve the right to revoke this authority at any time.

OR

In the event Section 6 is completed and valid, Section 5 does not apply.

6. I am a parent or legal guardian on active duty as governed by KRS Chapter 403A.

My active duty service is scheduled to begin on ___________________, 20__, and is

estimated to end on __________________________, 20__. I acknowledge that in no

event may this delegation of power last more than one (1) year or the term of my active

duty plus thirty (30) days, whichever is longer.

7. BY: ______________________________________________________________

(Parent/Legal Guardian signature)

8. I hereby accept my designation as Attorney -in-fact for the minor child or children

specified in this power of attorney.

__________________________________________________________

(Attorney-in-fact signature)

County of __________________

ACKNOWLEDGMENT

Before me, the undersigned, a Notary Public, in and for said County and State on this

____day of ___________________________, 20___, personally appeared

______________________________

(Name of Parent/Legal Guardian)

______________________________

(Name of Attorney-in-fact),

to me known to be the identical persons who executed this instrument and acknowledged

to me that each executed the same as his or her free and voluntary act and deed for the

uses and purposes set forth in the instrument.

Witness my hand and official seal the day and year above written.

_________________________

(Signature of notary public)

My commission expires: _________________."

(2) The power of attorney is legally sufficient under this section, KRS 403.352, and

KRS Chapter 403A if the wording of the for m complies substantially with

subsection (1) of this section, the form is properly completed and signed, and the

form or parties are not otherwise invalid pursuant to KRS 403.352.