Connecticut Power of Attorney for a Child
This Power of Attorney document is designed to grant legal authority from the parent(s) or legal guardian(s) of a child to a trusted individual, for making decisions regarding the child's welfare, education, and healthcare in the State of Connecticut, in accordance with the Connecticut Uniform Power of Attorney Act.
NOTICE: This legal form is intended for use as a guideline. It is advised that both the granting and receiving parties consult with a legal professional before executing this document. This document does not substitute for legal advice or services. Refer to your state’s requirements for additional stipulations.
1. Parties Information:
Parent(s)/Legal Guardian(s) Information:
Name: ___________________________________________
Address: ____________________________________________
Phone Number: _______________________________________
Email Address: _______________________________________
Attorney-in-Fact Information:
Name: ___________________________________________
Address: ____________________________________________
Phone Number: _______________________________________
Email Address: _______________________________________
2. Child Information:
Child’s Full Name: _______________________________________
Date of Birth: __________________________________________
Address: _______________________________________________
3. Terms and Conditions:
This Power of Attorney shall be effective on ___________ [insert date] and shall remain in effect until ___________ [insert date], unless earlier revoked in writing by the undersigned parent(s) or legal guardian(s).
The appointed Attorney-in-Fact is granted authority to act on behalf of the child in matters pertaining to the child's personal care, education, and health care decisions, or as otherwise defined here:
- Medical decisions, including the power to consent to medical, dental, and mental health treatment.
- Educational decisions, including enrollment, day-to-day activities, and permission for school trips.
- Authorization to travel with the child within the United States or internationally.
- Other: ___________________________________________________________.
4. Signatures:
This document is not valid unless signed by the Parent(s)/Legal Guardian(s), the Attorney-in-Fact, and notarized.
______________________________ ______________________________
Signature of Parent/Legal Guardian Date
______________________________ ______________________________
Signature of Second Parent/Legal Guardian (if applicable) Date
______________________________ ______________________________
Signature of Attorney-in-Fact Date
STATE OF CONNECTICUT
COUNTY OF ______________________
The foregoing instrument was acknowledged before me this _____ day of ___________, 20___, by the above-named parent(s)/legal guardian(s) and Attorney-in-Fact.
______________________________
Notary Public
My Commission Expires: __________
DISCLAIMER: This form is provided ‘AS-IS’ without any warranty of any kind, expressed or implied, statutory or otherwise. Any use of this form is at your own risk, and should be reviewed by an attorney in your jurisdiction before being used as a legal document. By using this form, you agree that the templates provided will not be used as legal advice, and no attorney-client relationship is established with its use.