Section 19-9-134 - Power of attorney form(a) The power of attorney contained in this Code section may be used for the temporary delegation of caregiving authority to an agent. The form contained in this Code section shall be sufficient for the purpose of creating a power of attorney under this article, provided that nothing in this Code section shall be construed to require the use of this particular form.(b) A power of attorney shall be legally sufficient if the form is properly completed and the signatures of the parties are notarized.(c) The power of attorney delegating caregiving authority of a child shall be in substantially the following form: "FORM FOR POWER OF ATTORNEY TO DELEGATE THE POWER AND AUTHORITY FOR THE CARE OF A CHILD NOTICE:
(1) THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE INDIVIDUAL WHOM YOU DESIGNATE (THE AGENT) POWERS TO CARE FOR YOUR CHILD, INCLUDING THE POWER TO: HAVE ACCESS TO EDUCATIONAL RECORDS AND DISCLOSE THE CONTENTS TO OTHERS; ARRANGE FOR AND CONSENT TO MEDICAL, DENTAL, AND MENTAL HEALTH TREATMENT FOR THE CHILD; HAVE ACCESS TO RECORDS RELATED TO SUCH TREATMENT OF THE CHILD AND DISCLOSE THE CONTENTS OF THOSE RECORDS TO OTHERS; PROVIDE FOR THE CHILD'S FOOD, LODGING, RECREATION, AND TRAVEL; AND HAVE ANY ADDITIONAL POWERS AS SPECIFIED BY THE INDIVIDUAL EXECUTING THIS POWER OF ATTORNEY.(2) THE AGENT IS REQUIRED TO EXERCISE DUE CARE TO ACT IN THE CHILD'S BEST INTERESTS AND IN ACCORDANCE WITH THE GRANT OF AUTHORITY SPECIFIED IN THIS FORM.(3) A COURT OF COMPETENT JURISDICTION MAY REVOKE THE POWERS OF THE AGENT.(4) THE AGENT MAY EXERCISE THE POWERS GIVEN IN THIS POWER OF ATTORNEY FOR THE CARE OF A CHILD FOR THE PERIOD SET FORTH IN THIS FORM UNLESS THE INDIVIDUAL EXECUTING THIS POWER OF ATTORNEY REVOKES THIS POWER OF ATTORNEY AND PROVIDES NOTICE OF THE REVOCATION TO THE AGENT OR A COURT OF COMPETENT JURISDICTION TERMINATES THIS POWER OF ATTORNEY.(5) THE AGENT MAY RESIGN AS AGENT AND MUST IMMEDIATELY COMMUNICATE SUCH RESIGNATION TO THE INDIVIDUAL EXECUTING THIS POWER OF ATTORNEY AND TO SCHOOLS, HEALTH CARE PROVIDERS, AND OTHERS KNOWN TO THE AGENT TO HAVE RELIED UPON SUCH POWER OF ATTORNEY.(6) THIS POWER OF ATTORNEY MAY BE REVOKED IN WRITING. IF THIS POWER OF ATTORNEY IS REVOKED, THE REVOKING INDIVIDUAL SHALL NOTIFY THE AGENT, SCHOOLS, HEALTH CARE PROVIDERS, AND OTHERS KNOWN TO THE INDIVIDUAL EXECUTING THIS POWER OF ATTORNEY TO HAVE RELIED UPON SUCH POWER OF ATTORNEY.(7) IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK AN ATTORNEY TO EXPLAIN IT TO YOU. STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent) who, after having been sworn, deposes and says as follows:
1. I certify that I am the parent of: __________________
(Full name of child) (Date of birth)
2. I designate: __________________, (Full name of agent)
__________________
(Street address, city, state, and ZIP Code of agent)
__________________,
(Personal and work telephone numbers of agent)
as the agent of the child named above.
3. The agent named above is related or known to me as follows (write in your relationship to the agent; for example, aunt of the child, maternal grandparent of the child, sibling of the child, god-parent of the child, associated with a nonprofit or faith based : organization)__________________4. Sign by the statement you wish to choose (you may only choose one):(A) __________________ (Signature) The agent named above is related to me by blood or marriage and I have elected not to have him or her obtain a criminal background check. OR
(B) __________________ (Signature) The agent named above is not related to me and I have reviewed his or her criminal background check. (If the agent has a criminal con-viction, complete the rest of this paragraph.) I know that the agent has a conviction but I want him or her to be the agent because (write in): __________________ __________________
__________________
5. Sign by the statement you wish to choose (you may only choose one): (A) __________________ (Signature) I delegate to the agent all my power and authority regarding the care and custody of the child named above, including but not limited to the right to inspect and obtain copies of educational records and other records concerning the child, attend school activities and other functions concerning the child, and give or withhold any consent 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 the 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. OR
(B) __________________ (Signature) I delegate to the agent the following specific powers and responsibilities (write in): __________________ __________________
This delegation shall not include the power or authority to consent to the 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.
6. Initial by the statement you wish to choose (you may only choose one of the three options) and complete the information in the paragraph: (A) __________________ (Initials) This power of attorney is effec-tive for a period not to exceed one year, beginning __________________, 2__________________, and ending __________________, 2__________________. I reserve the right to revoke this power and author-ity at any time. OR
(B) __________________ (Initials) This power of attorney is being given to a grandparent of my child and is effective until I revoke this power of attorney. OR
(C) __________________ (Initials) I am a parent as described in O.C.G.A. § 19-9-132(b). My deployment is scheduled to begin on __________________, 2__________________, and is estimated to end on __________________, 2__________________. I acknowledge that in no event shall this delegation of power and authority last more than one year or the term of my deployment plus 30 days, whichever is longer. I reserve the right to revoke this power and authority at any time.7. I hereby swear or affirm under penalty of law that I provided the notice required by O.C.G.A. § 19-9-125 and received no objec-tion in the required time period. By: __________________
(Parent signature)
__________________
(Printed name)
__________________
(Street address, city, state, and ZIP Code of parent)
__________________
(Personal and work telephone numbers of parent)
Sworn to and subscribed
before me this __________________
day of __________________, __________________.
__________________
Notary public (SEAL)
My commission expires: __________________.
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of agent) who, after having been sworn, deposes and says as follows:
8. I hereby accept my designation as agent for the child specified in this power of attorney and by doing so acknowledge my accep-tance of the responsibility for caring for such child for the duration of this power of attorney. Furthermore, I hereby certify that: (A)(i) I am related to the individual giving me this power of attorney by blood or marriage as follows (write in your relationship to the individual designating you as agent; for example, sister, mother, father, etc.): __________________ OR
(ii) I am not related to the individual giving me this power of attorney but was referred to him or her by: __________________ (write in the name of the child-placing agency, nonprofit entity, or faith based organization).(B) I am not currently on the state sexual offender registry of this state or the sexual offender registry or child abuse registry for any other state, a United States territory, the District of Columbia, or any American Indian tribe nor have I ever been required to register for any such registry;(C) I have provided a criminal background check to the individual designating me as an agent, if it was required;(D) I understand that I have the authority to act on behalf of the child: * For the period of time set forth in this form; * Until the power of attorney is revoked in writing and notice is provided to me as required by O.C.G.A. § 19-9-130; or * Until the power of attorney is terminated by order of a court;
(E) I understand that if I am made aware of the death of the individual who executed the power of attorney, I must notify the surviving parent of the child, if known, as soon as practi-cable; and(F) I understand that I may resign as agent by notifying the individual who executed the power of attorney in writing by certified mail, return receipt requested, or statutory overnight delivery and I must also notify any schools, health care providers, and others to whom I give a copy of this power of attorney. __________________
(Agent signature)
__________________
(Printed name)
Sworn to and subscribed
before me this __________________
day of __________________, __________________.
__________________
Notary public (SEAL)
My commission expires: __________________.
__________________
(Organization signature, if applicable)
__________________
(Printed name and title)"
Amended by 2020 Ga. Laws 410,§ 4, eff. 7/1/2020.Amended by 2019 Ga. Laws 321,§ 19, eff. 5/12/2019.Added by 2018 Ga. Laws 285,§ 2-2, eff. 9/1/2018.