Parental Designation

Please correct the errors described below.

am/are the parent(s) of

And I/We have the power to make medical decisions for my/our child. There are no court orders that limit power or that prohibits me/us from making this designation

By signing below, I/we designate the following person(s), who are over the age of eighteen:

to have parental relation to my child named above this designation can only be revoked by a court order

Contact information of Parent(s) and the Designee (listed above only)

During the period of this designation

Add Additional Designee

The person(s) I designate on this form shall have the powers and duties permitted or imposed by NYS law of a person in a parental relation except:

This designation is good for ONE YEAR from the date of signature below unless revoked by court order.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.