FORM

CONSENT OF PARENT OR GUARDIAN FOR MEDICAL TREATMENT OF MINOR CHILD

(This form will not supersede any court ruling regarding custody, visitation, or right to make legal or medical decisions on behalf of a minor child.)

WHEREAS, I, the undersigned Parent, affirm that I am the parent or legal guardian of the Child and I am authorized to sign this document;

WHEREAS, I wish for the Custodian to be able to take custody of and care for care of the Child from time to time on a temporary basis (in other words, baby-sit for the Child); and

WHEREAS, if the Child had a medical emergency while in the Custodian's custody, and I were unable to be contacted to consent to medical treatment, the Custodian might have no legal ability to consent to treatment of the Child without this document;

Therefore, I hereby make, constitute and appoint Custodian as my true and lawful health care attorney-in-fact with respect to all health care matters regarding Child while the Child is in the temporary custody of Custodian, upon the terms and conditions hereinafter set forth. I intend this document to comply with the requirements of A.R.S. Section 36-3221.

1. First Try To Contact Me. The treating health care professionals should first attempt to contact me to obtain my authorization for any needed medical treatment of the Child. If I cannot be reached within a reasonable time (as determined by the treating physician or other health care professionals), then the Custodian shall be authorized to provide consent to any and all medical treatment as further set forth below.

2. Consent to Treatment. The rights and authority conferred on the Custodian herein appointed shall include, but are by no means limited to, the right to receive information and reports from all treating physicians, other health care professionals, health care institutions, etc., regarding proposed health care, surgery, or any other aspect of the Child's medical treatment; the right to receive and review the Child's medical records and information to the same extent that I am entitled to and to disclose or consent to the disclosure of the Child's medical records to others; to contract on my behalf for any health care related service or facility for Child's benefit (without the Custodian incurring personal financial liability for such contracts); and to hire and fire medical, social service and other support personnel responsible for the Child's care.

3. Limitations on Consent: I do not consent to the following medical treatment being administered to the Child:
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(If this is not applicable, write "N/A")

4. Hold Harmless. I hold the treating physician, other health care professionals, and health care institutions involved in providing care for Child harmless from their decision(s) regarding whether to accept the Custodian's consent to treatment and/or actions in reliance on this document.

No person who relies in good faith upon any representations by the Custodian shall be liable to Parent, Child, Child's estate, or Child's heirs or assigns, for recognizing the Custodian's authority. The directions of the Custodian shall be binding in all respects upon all those involved in the Child's care. Custodian and all those acting upon his or her directions shall be entitled to indemnification from the Parent and Child's estate in connection with all claims asserted against them, unless the directions given and relied on are wholly inconsistent with my intentions as expressed herein.

5. Special Instructions to Custodian (use additional sheet if necessary):
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(If this is not applicable, write "N/A")

On this date, , the foregoing instrument was acknowledged before me and in my presence by the above-named parent or legal guardian, who acknowledged (a) that he/she is a parent or legal guardian of the above-named minor child, (b) that he/she is at least 18 years of age, (c) that he/she, being authorized to do so, dated and signed the foregoing instrument for the purposes contained therein. The above-named parent or legal guardian appeared to be of sound mind and free from duress at the time of execution of the foregoing instrument.

I affirm that I am not the designated Custodian and I was not directly involved with the provision of health care to the Minor Child at the time this document was executed.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.