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Back to Forms for 'Living Wills'.





Whereas, _______________________ and _____________________ are the parents and natural guardians of the following child(ren):



Name                                       Age                  Date of Birth



Name                                       Age                  Date of Birth



Name                                       Age                  Date of Birth


I appoint ________________________________________________ (Name and Address) to act as guardian of the minor child(ren) stated above upon my inability to so act.

Should _______________________________ be unable or unwilling to serve, I appoint ________________________________________________ (Name and Address) to act as the guardian of the minor children in the place of ______________________________.

Upon my disability, the designated guardian shall have the following authority:


a) residential custody of the minor child(ren);


b) to approve medical treatment of any kind or type or to disapprove the same within the bounds of the law;


c) to designate schooling for the minor children, and access to any and all of their educational records;


d) to generally act in loco parentis,


In the event that I am the custodian of any property for the minor children under the Uniform Transfer to Minors Act, or the Uniform Gifts to Minors Act or similar statute, I designate the guardian or successor guardian to act as custodian for all such custodial property.


In the event that formal legal proceedings are commenced to establish a guardian for the child, it is my desire that the guardians mentioned herein have priority in appointment.

The failure to list an individual as a guardian or successor guardian is intentional.



___________________________                                       _______________

Signature                                                                               Date


___________________________                                       _______________

Signature                                                                               Date


___________________________                                       _______________

Signature                                                                               Date



I certify that ______________________________ has appeared before me on this day of

_______________ (Date).  I am a notary public in the County of ___________ in the State of _________________. 


My commission expires on _________________



Notary Public

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