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ALABAMA DELEGATION OF PARENTAL AUTHORITY

TO WHOM IT MAY CONCERN:

Pursuant to Code of Alabama 1975, Section 26-2A-7, I, legal custodian of the child(ren) identified below, do hereby delegate to

Print of Type Name(s) of Person(s) To Whom Authority Is Given

Print of Type Address

Print or Type City. State. Zip. and Telephone Number

a limited power of attorney granting physical custody and authority to make any decision relating to the child(ren)'s physical custody. health. education. or maintenance.

Child(ren)'s Name Date of Birth

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

This authority includes the power to grant permission or consent for medical treatment. surgery. trips. and participation in athletic events, No power is given to consent to the child(ren)’s marriage or adoption.

This authority expires one (1) year from the date shown below unless cancelled. verbally or in writing. by

me prior to that time.

Print or Type Legal Custodian's Name Signature

Print or Type Legal Custodian's Name Signature

Print or Type Legal Custodian's Address Date

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Print or Type Witness Name Signature

Date

DHR-FCS-2111 (September 2002)

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