PARENTAL CONSENT (Minor)

POWER OF ATTORNEY
Parental Consent for temporary Guardian

for Arizona and New Mexico
I/We _____________________________________________, after being duly sworn do solemnly

(Name(s) of Natural Parent(s)
swear as follows:
1. I/we am an enrolled member(s) of the Navajo Nation and reside at_____________________

(Address of Natural Parent(s)
____________________________________________________________________________________.
2. I am/we are the natural parent(s) of:
NAME C# DOB:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________
3. The above named child(ren) will be attending school

at____________________________________
(Name of School(s)
_________________________________________________for the 20_____ to 20_____ academic year.
4. During the time the child(ren) will be residing/living with

__________________________________
Guardian’s Name(s)
__________________________________ who is/are related to the child(ren)/know the children
because
____________________________________________________________________________________.
(Write in the Relationship to Child(ren)
5. I/we do hereby make, constitute and appoint__________________________________________
(Guardian’s Name)
as my true and lawful attorney solely for the purpose of performing all the parental
responsibilities as
I/we might perform myself/ourselves with regard to my/our child(ren).
6. This Power of Attorney is effective for a period of six (6) months pursuant to N.M.S.A.
§445-5-
104 or A.R.S. §14-5104, unless revoked in writing prior to the end of the six months.
7. Although I/we will continue to be informed of my/our child(ren) progress and activities
in
school, the guardian,_______________________________________ has my/our consent to act as

legal
(Guardian’s Name(s)
guardian for the above-named child(ren), and has all powers necessary for the proper care
and control
Page 1 of 4
of my child(ren).
8. This guardianship agreement is temporary and will last six (6) months from the date
I/we sign this
unless I revoke it at an earlier time.
I/we _______________________________________________ solemnly swear the foregoing

(Name of Parent(s)
Power of Attorney is true to the best of my/our knowledge.
_________________ _____________________________________
Date Signature
_________________ _____________________________________
Date Signature
STATE OF_________________ )
) SS:
COUNTY OF _______________ )
SUBSCRIBED and SWORN before me this___________ day of_____________, 20______.
____________________________________
Notary of Public
My Commission Expires: ____________________
Page 2 of 4
PARENTAL CONSENT FOR MEDICAL TREATMENT
I/we _____________________________________________, after being duly sworn do solemnly

(Name(s) of Natural Parent(s)
swear as follows:
1. I am/we are enrolled member(s) of the Navajo Nation and reside at:
____________________________________________________________________________________.
(Address of Natural Parent(s)
2. I am/we are the natural parent(s) of:
NAME C# DOB:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________
3. I/we authorized the guardian(s), ______________________________________________,

(Name(s) of Guardian(s)
an adult(s) in whose care the minor(s) has been entrusted and who resides at
______________________
(Address of Guardian(s)
_____________________________________________________________________________________,
to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or

treatment, and
hospital care to be rendered to the minor child(ren) under the general and special
supervision and on the
advice of any physician, surgeon or dentist licensed to practice, and further to consent to any
other
medical treatment which is in the guardian’s best judgment and is beneficial to the
child(ren).

(Natural Parent(s)
Power of Attorney is true, made in the best judgment and is beneficial to the child(ren).
This consent and authorization shall last for six (6) months from the date I/we execute
this.
__________________ _________________________________________
Date Signature
__________________ _________________________________________
Date Signature
STATE OF _______________ )
) SS:
COUNTY OF _____________ )
SUBSCRIBED and SWORN before me this _________ day of______________, 20______.
Page 3 of 4
____________________________________
Notary of Public
My Commission Expires: ___________________
ACCEPTANCE/CONCURRENCE BY GUARDIAN
I/we ____________________________________________, have read the Parental Consent

made
(Guardian(s) Name(s)
by_______________________________________ who is/are the natural parent(s) of:

(Name of Natural Parent(s)
NAME C# DOB:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________
I/we accept this appointment and concur that I/we have agreed with the natural
parent(s) to
care for the above named child(ren) for six (6) months or, if a shorter amount of time, until
this
date: _________________________________________.
(Insert date if you are accepting if for a shorter amount of time)

(Name of Guardian(s)
Power of Attorney is true to the best of my/our knowledge.
__________________ _______________________________________
Date Signature
__________________ _______________________________________
Date Signature
STATE OF _______________ )
) SS:
COUNTY OF _____________ )
SUBSCRIBED and SWORN before me this___________ day of_____________, 20________.
____________________________________
Notary of Public
My Commission Expires: ____________________
Page 4 of 4

PARENTAL CONSENT (Minor)

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PARENTAL CONSENT (Minor)

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POWER OF ATTORNEY

Parental Consent for temporary Guardian

I/We _____________________________________________, after being duly sworn do solemnly

1. I/we am an enrolled member(s) of the Navajo Nation and reside at_____________________

2. I am/we are the natural parent(s) of:

3. The above named child(ren) will be attending school

4. During the time the child(ren) will be residing/living with

I/we might perform myself/ourselves with regard to my/our child(ren).

school, the guardian,_______________________________________ has my/our consent to act as

unless I revoke it at an earlier time.

I/we _______________________________________________ solemnly swear the foregoing

SUBSCRIBED and SWORN before me this___________ day of_____________, 20______.

My Commission Expires: ____________________

I/we _____________________________________________, after being duly sworn do solemnly

3. I/we authorized the guardian(s), ______________________________________________,

to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or

I/we _______________________________________________ solemnly swear the foregoing

SUBSCRIBED and SWORN before me this _________ day of______________, 20______.

I/we ____________________________________________, have read the Parental Consent

by_______________________________________ who is/are the natural parent(s) of:

I/we _______________________________________________ solemnly swear the foregoing

SUBSCRIBED and SWORN before me this___________ day of_____________, 20________.

My Commission Expires: ____________________

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