OHIO LIMITED POWER OF ATTORNEY FOR CHILD CARE

We, ______________and_____________, presently residing at ___________________, as the parent(s)and/or custodian(s) of ______________________, hereinafter referred to as the child/children, hereby delegate to ____________________ , hereinafter referred to as my/our agent, the authority to act in my/our place and stead with respect to each of the following powers:
1. To consent to any necessary medical treatment, surgery, medication, therapy, hospitalization or other such care of or for the child/children;
2. To employ, retain or discharge any person who may care for, counsel, treat or in any manner assist the child/children.
3. To exercise the same parental rights I/we may exercise with respect to the care, custody and control of the child/children, and the discretion to exercise the same rights in my/our agent's home or any other place selected by my/our agent in his/her discretion.
4. To perform all other acts necessary, or incidental to the execution of the powers enumerated herein;
Any lawful act performed by my/our agent shall be binding upon myself/ourselves, my/our heirs, beneficiaries, personal representatives and assigns. I/We reserve the right to amend or revoke this Limited Power of Attorney at any time hereafter; provided, however, any institution or other party dealing with my agent may rely upon this Limited Power of Attorney until receipt by it of a duly executed copy of my revocation thereof.
Any reproduced copy of this signed original shall be deemed to be an original counterpart of this Limited Power of Attorney. This Limited Power of Attorney shall not be affected by any legal incapacity during my lifetime, except as provided by statute.
This Limited Power of Attorney shall remain in effect from _________________________ and terminate upon a subsequent written revocation or on__________________________, whichever shall occur first.
Dated: _______________________
Signatures: 
______________________________ 
______________________________
STATE OF _________________		)
						)   SS
COUNTY OF ________________	)

	BE IT REMEMBERED, that on this _________ day of _________________, 20____, before me, the subscriber, a Notary Public in and for said County and State, personally came ____________________ and acknowledged the signing of the foregoing instrument, and that the same is his voluntary act and deed.

	IN TESTIMONY WHEREOF, I have hereunto subscribed my name and affixed my notarial seal on the day and year first above written.

					 	___________________________________ 								Notary Public
							My Commission Expires: