(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, godparent 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 conviction, 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 effective

for a period not to exceed one year, beginning , 2 ,

and ending , 2 . I reserve the right to revoke this

power and authority 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.

§ 19-9-130(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 objection 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 acceptance 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

or child abuse 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 practicable;

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)"