Power of Attorney

I, ______________________________, being of sound mind and body, declare the following:

1. That I am the natural mother (father) of ________________________________________________________________.
    
2. That I am presently incarcerated at ________________________________________________________________.
    
3. That, during this time, my ___________________________ is being cared for by _________________________________________.
    
4. That I wish to give full Power of Attorney to ___________________________ with respect to the care and custody of my ____________________________________.
    
5. That, specifically, I give ___________________________ full Power of Attorney with respect to the care and custody of ______________________________ in matters affecting _____ medical needs, schooling, public assistance and Medi-Cal, legal matters, and all other matters pertaining to the well-being of my child.

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