Vermont Power of Attorney for a Child
This Vermont Power of Attorney for a Child (“Document”) is a legal document designed to temporarily grant certain parental or guardian rights to an appointed individual (“Agent”) for the purpose of caring for a minor child or children in the absence of the child’s parent(s) or legal guardian(s). By executing this Document, the parent(s) or legal Guardian(s) do not relinquish their parental rights but authorize the Agent to act in specific, agreed-upon matters concerning the child’s welfare. The conditions under which this Document is created follow the guidelines outlined in the Vermont Statutes, particularly those relevant to the temporary delegation of parental rights and responsibilities.
Please complete the following information to ensure the Document accurately reflects the agreement:
1. Child’s Information:
- Full Name: _______________________________________________
- Date of Birth: ____________________________________________
- Primary Address: __________________________________________
2. Parent(s)/Legal Guardian(s) Information:
- Full Name(s): _____________________________________________
- Relationship to Child: ____________________________________
- Primary Address: __________________________________________
- Contact Information: ______________________________________
3. Agent’s Information:
- Full Name: _______________________________________________
- Relationship to Child: ____________________________________
- Primary Address: __________________________________________
- Contact Information: ______________________________________
4. Powers Granted: Indicate below the specific powers and responsibilities the Agent is authorized to assume concerning the care of the child. Attach additional pages if necessary.
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5. Term of Document: Specify the date of commencement and expiration for the powers granted to the Agent. In the absence of an expiration date, this Document shall remain in effect for a period not exceeding six (6) months, in accordance with Vermont law.
- Commencement Date: _______________________________________
- Expiration Date (if applicable): ____________________________
6. Signatures: This Document must be signed in the presence of a notary public or two (2) witnesses to be legally valid.
Parent(s)/Legal Guardian(s) Signature:
Signature: ___________________________________ Date: ________________
Print Name: __________________________________
Agent’s Signature:
Signature: ___________________________________ Date: ________________
Print_ Name: __________________________________
Witnesses/Notary (as applicable):
Signature: ___________________________________ Date: ________________
Print Name: __________________________________
7. Revocation: The parent(s) or legal guardian(s) reserve the right to revoke this Power of Attorney at any time, provided the revocation is made in writing and delivered to the Agent.
By executing this Vermont Power of Attorney for a Child, the parent(s) or legal guardian(s) acknowledge that they have read, understood, and agree to all terms and conditions set forth in this Document.