 | Missouri Minor Child Power of Attorney Form |
The Missouri minor child power of attorney form is a document that will permit a parent to select an Attorney In Fact/Agent in the event the parent(s) would have to be absent from the child(ren) more than they should, in order to provide proper care. This particular document allows the temporary Agent to provide medical care as needed, while the child is in their care. The form will contain, not only permission to sign for treatment but will also provide medical history for the child(ren)
This document may be revoked by the parent(s) at their discretion. This document must be signed before a licensed notary public
How to Write
Step 1 – Download the document – Enter the following:
- The name of the appointed Agent
- The name(s) of the child(ren) – If there is more than one child who will be in the care of the Agent(s), provide an added sheet and attach it to this form, with the children’s information or complete one form per child.
- Read the remainder of the document before proceeding
Step 2 – Date and Parent’s Signature –
- Enter the date that the document is executed in mm/dd/yyyy format
- Provide the parent’s signature
- Date the parent’s signature in mm/dd/yyyy format
- Second parent’s signature
- Date the second parent’s signature in mm/dd/yyyy format
Notarization –
- As the Notary Public witnesses the signatures, they shall complete this section with their information, acknowledging the signatures and the validity of the document
Step 3 – Medical History – Submit the following information:
- Child(ren’s) Name(s)
- Child(ren’s) Birth Date in mm/dd/yyyy format
- Allergies
- Religion
- Blood Type
- Date of Last Tetanus Shot in mm/dd/yyyy format
- Previous Hospitalizations and Major Illnesses
- Current Medications (if any)
- Pediatrician Telephone
- Other Important Information (add other information that the guardian may need to know)
Step 4 – Added Information – Complete the following:
- Father’s Name
- Home Phone
- Home Address
- Place of Employment
- Work Phone
- AND
- Insurance Company
- Policy Number
- AND
- Mother’s Name
- Home Phone
- Home Address
- Place of Employment
- Work Phone
- Insurance Company
- Policy Number
