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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
Print or Type Legal Custodian's City, State, Zip
Print or Type Witness Name Signature
Date
DHR-FCS-2111 (September 2002)
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