Relationship of agent to child(ren) ....
The parental power I am delegating is as follows:
FULL
(Check if you want to delegate full parental power regarding the care and custody of the child(ren) named above.)
.... Full parental power regarding the care and custody of the child(ren) named above
PARTIAL
(Check each subject over which you want to delegate your parental power regarding the child(ren) named above.)
.... The power to consent to all health care; or
.... The power to consent to only the following health care:
.... Ordinary or routine health care, excluding major surgical procedures, extraordinary procedures, and experimental treatment
.... Emergency blood transfusion
.... Dental care
.... Disclosure of health information about the child(ren)
.... The power to consent to educational and vocational services
.... The power to consent to the employment of the child(ren)
.... The power to consent to the disclosure of confidential information, other than health information, about the child(ren)
.... The power to provide for the care and custody of the child(ren)
.... The power to consent to the child(ren) obtaining a motor vehicle operator’s license
.... The power to travel with the child(ren) outside the state of Wisconsin
.... The power to obtain substitute care, such as child care, for the child(ren)
.... Other specifically delegated powers or limits on delegated powers (Fill in the following space or attach a separate sheet describing any other specific powers that you wish to delegate or any limits that you wish to place on the powers you are delegating.) ....
This delegation of parental powers does not deprive a custodial or noncustodial parent of any of his or her powers regarding the care and custody of the child, whether granted by court order or force of law.
THIS DOCUMENT MAY NOT BE USED TO DELEGATE THE POWER TO CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN), THE PERFORMANCE OR INDUCEMENT OF AN ABORTION ON OR FOR THE CHILD(REN), THE TERMINATION OF PARENTAL RIGHTS TO THE CHILD(REN), THE ENLISTMENT OF THE CHILD(REN) IN THE U.S. ARMED FORCES OR TO PLACE THE CHILD(REN) IN A FOSTER HOME, GROUP HOME, SHELTER CARE FACILITY, OR INPATIENT TREATMENT FACILITY.
EFFECTIVE DATE AND TERM
OF THIS DELEGATION
This Power of Attorney takes effect on .... and will remain in effect until .... If no termination date is given, this Power of Attorney will remain in effect for a period of one year after the effective date, but no longer. If the termination date given is more than one year after the effective date of this Power of Attorney, this Power of Attorney must be approved by the juvenile court. This Power of Attorney may be revoked in writing at any time by a parent who has legal custody of the child(ren) and such a revocation invalidates the delegation of parental powers made by this Power of Attorney, except with respect to acts already taken in reliance on this Power of Attorney.
SIGNATURE(S) OF PARENT(S)
Signature of parent .... Date ....
Parent’s name printed ....
Parent’s address ....
Parent’s telephone number ....
Parent’s e-mail address ....
Signature of parent .... Date ....
Parent’s name printed ....
Parent’s address ....
Parent’s telephone number ....
Parent’s e-mail address ....
WITNESSING OF SIGNATURE(S) (OPTIONAL)
State of ....
County of ....
This document was signed before me on .... (date) by .... (name(s) of parent(s)).
Signature of notary ....
My commission expires: ....
STATEMENT OF AGENT
I, .... (name and address of agent), understand that .... (name(s) of parent(s)) has (have) delegated to me the powers specified in this Power of Attorney regarding the care and custody of .... (name(s) of child(ren)). I further understand that this Power of Attorney may be revoked in writing at any time by a parent who has legal custody of .... (name(s) of child(ren)). I hereby declare that I have read this Power of Attorney, understand the powers delegated to me by this Power of Attorney, am fit, willing, and able to undertake those powers, and accept those powers.
Agent’s signature .... Date ....
APPENDIX
(Here the parent(s) may indicate where they may be located during the term of the Power of Attorney if different from the address(es) set forth above.)
.... I can be located at:
Address(es) ....
Telephone number(s) ....
E-mail address(es) ....
.... Or, by contacting:
Name ....
Address ....
Telephone number ....
E-mail address ....
.... Or, I cannot be located
48.979(3)(a)1.1. “Agent” means a person to whom delegation of the care and custody of a child under this section is facilitated by an organization. 48.979(3)(a)2.2. “Organization” means an organization that facilitates delegations of the care and custody of children under this section. 48.979(3)(b)(b) The department may promulgate rules to implement this section. If the department promulgates those rules, those rules shall include rules establishing all of the following: 48.979(3)(b)1.1. Training requirements for the staff of an organization, including training in identifying children who have been abused or neglected and the laws and procedures under s. 48.981 governing the reporting of suspected or threatened child abuse or neglect. 48.979(3)(b)2.2. Screening and assessment requirements for a proposed agent, including a screening of the personal characteristics, health, and finances of the proposed agent and of the physical environment and safety of the proposed agent’s home and, based on that screening, an assessment of the proposed agent’s fitness to provide for the care and custody of the child and ability to meet the child’s needs. The rules promulgated under this subdivision shall prohibit an organization from facilitating a delegation of the care and custody of a child to a proposed agent unless the proposed agent is fit to provide for the care and custody of the child and able to meet the child’s needs. 48.979(3)(b)3.3. Training requirements for an agent, including the training described in subd. 1. and training in the expectations of an agent specified in subd. 4. 48.979(3)(b)4.4. The expectations of an agent with respect to the care and custody of the child, including expectations relating to the care, nurturing, protection, training, guidance, and discipline of the child; the provision of food, shelter, education, and health care for the child; cooperation with the child’s parents in coparenting the child; and cooperation with the organization in facilitating visitation and other communications with the child’s parents and in otherwise complying with the expectations of the organization. 48.979(3)(b)5.5. A requirement that an organization regularly monitor an agent and the child whose care and custody is delegated to the agent and maintain communications with the child’s parents. 48.979548.9795 Appointment of guardian of the person for a child. 48.9795(1)(a)1.1. For purposes of a petition for guardianship of a child, any of the following: 48.9795(1)(a)1.a.a. The child, if he or she has attained 12 years of age, and the child’s guardian ad litem and counsel, if any. 48.9795(1)(a)1.b.b. The child’s parent, guardian, legal custodian, and physical custodian. 48.9795(1)(a)1.c.c. Any person who has filed a declaration of paternal interest under s. 48.025, who is alleged to the court to be the father of the child, or who may, based on the statements of the mother or other information presented to the court, be the father of the child. 48.9795(1)(a)1.d.d. Any individual who is nominated as guardian or as a successor guardian. 48.9795(1)(a)1.e.e. If the child has no living parent, any individual nominated to act as fiduciary for the child in a will or other written instrument that was executed by a parent of the child. 48.9795(1)(a)1.f.f. If the child is receiving or in need of any public services or benefits, the county department or, in a county having a population of 750,000 or more, the department that is providing the services or benefits, through the district attorney, corporation counsel, or other officials designated under s. 48.09. 48.9795(1)(a)1.g.g. If the child is an Indian child, the Indian child’s Indian custodian and Indian tribe. 48.9795(1)(a)2.2. For purposes of proceedings subsequent to an order for guardianship of a child, any of the following: 48.9795(1)(a)2.a.a. The child, if the child has attained 12 years of age, the child’s guardian ad litem, and the child’s counsel. 48.9795(1)(a)2.c.c. The county of venue, through the district attorney, corporation counsel, or other official designated under s. 48.09, if the county has an interest in the guardianship. 48.9795(1)(b)(b) “Party” means the person petitioning for the appointment of a guardian for a child or any interested person other than a person who is alleged to the court to be the father of the child or who may, based on the statements of the mother or other information presented to the court, be the father of the child. 48.9795(2)(2) Appointment; venue; nomination; duty and authority. 48.9795(2)(a)(a) Venue. Except as provided under par. (b) 2., venue for guardianship under this section shall be in the child’s county of residence, the county in which the child is physically present, or, if the child is a nonresident, the county in which the petitioner proposes that the child reside. The court may, upon a motion and for good cause shown, transfer the case, along with all appropriate records, to the county in which a dispositional order has been issued under this chapter.
