                                 CODE OF VIRGINIA

STATUTORY FORM FOR POWER OF ATTORNEY TO DELEGATE PARENTAL OR LEGAL CUSTODIAL
POWERS (§ 20-167)

A. A power of attorney to delegate parental or legal authority executed pursuant
to this chapter shall be substantially as follows:
			POWER OF ATTORNEY TO DELEGATE PARENTAL OR LEGAL CUSTODIAL POWERS

   1. I/We certify that I/we am/are the parent or legal custodian of:
   				Full name of minor child: _________________________ Date of birth:
   ________________
   				Full name of minor child: _________________________ Date of birth:
   ________________
   				Full name of minor child: _________________________ Date of birth:
   ________________

   2. I/We ________________ designate (insert full name, address, and phone
   number of designated attorney-in-fact) as the attorney-in-fact of each child
   listed above.

   3. I/We delegate to the attorney-in-fact all of my/our power and authority
   regarding the care, custody, and property of each minor child named above,
   including discharge of a newborn infant from the hospital of birth, the
   initial physical placement of a child with the prospective adoptive parent in
   accordance with the provisions of Title 63.2 of the Code of Virginia, the
   right to enroll the child in school, the right to inspect and obtain copies of
   education records and other records concerning the child, the right to attend
   school activities and other functions concerning the child, and the right to
   give or withhold any consent or waiver with respect to school activities,
   medical and dental treatment, and any other activity, function, or treatment
   that may concern the child. This delegation shall not include the power or
   authority to consent to marriage or adoption of the child, the performance or
   inducement of an abortion on or for the child, or the termination of parental
   rights to the child. I/We understand that this power of attorney shall not
   operate to change or modify any parental or legal rights, obligations, or
   authority established by an existing court order or deprive a parent or legal
   custodian of any parental or legal rights, obligations, or authority regarding
   the custody, visitation, or support of any child under Title 20 of the Code of
   Virginia, and I/we understand that I/we shall continue to be bound by any
   obligations in such order. By my/our signature below, I/we hereby certify that
   I/we am/are not executing this power of attorney for any unlawful purpose or
   for the primary purpose of enrolling my/our child/children in a school for the
   sole purpose of participating in the academic or interscholastic athletics
   programs provided by that school.
   				OR

   I/We delegate to the attorney-in-fact the following specific powers and
   responsibilities:
   				__________________________________________________________________
   				__________________________________________________________________.
   				This delegation shall not include the power or authority to consent to
   marriage or adoption of the child, the performance or inducement of an
   abortion on or for the child, or the termination of parental rights to the
   child. I/We understand that this power of attorney shall not operate to change
   or modify any parental or legal rights, obligations, or authority established
   by an existing court order or deprive a parent or legal custodian of any
   parental or legal rights, obligations, or authority regarding the custody,
   visitation, or support of any child under Title 20 of the Code of Virginia,
   and I/we understand that I/we shall continue to be bound by any obligations in
   such order. By my/our signature below, I/we hereby certify that I/we am/are
   not executing this power of attorney for any unlawful purpose or for the
   primary purpose of enrolling my/our child/children in a school for the sole
   purpose of participating in the academic or interscholastic athletics programs
   provided by that school.

   4. This power of attorney is effective for a period not to exceed 180 days,
   beginning ____________ (insert date) and ending _________ (insert date). I/We
   reserve the right to revoke this authority at any time.
   				OR

   I/We am/are a service member, as defined by &#xA7; 20-166 of the Code of
   Virginia, and am/are on, or am/are scheduled to be on, active duty for a
   period that is set to last longer than 180 days. This power of attorney is
   effective for a period not to exceed the period of active duty plus 30 days,
   beginning ___________ (insert date) and ending _________ (insert date). I/We
   reserve the right to revoke this authority at any time.
   				Signature(s) of parent/legal custodian: ___________________________ Date:
   _____________

   5. I hereby accept my designation as attorney-in-fact for the minor
   child/children specified in this power of attorney and agree to act at all
   times in the best interests of the child/children specified herein and within
   the limits of the powers delegated to me. I understand that this power of
   attorney does not change or modify any parental or legal rights, obligations,
   or authority established by an existing court order or deprive a parent or
   legal custodian of any parental or legal rights, obligations, or authority
   regarding the custody, visitation, or support of the child/children specified
   herein. By my signature below, I affirm that I have received notice of any
   existing court order regarding the custody, visitation, or support of the
   child/children and agree to honor the rights of a parent or legal custodian of
   the child/children as specified in such order.
   				Signature of attorney-in-fact: __________________________ Date:
   ____________

   6. I, ______________________________ (insert name of representative of
   licensed child-placing agency), on behalf of ________________________ (insert
   name of licensed child-placing agency), hereby approve the designation of the
   aforementioned attorney-in-fact for the minor child/children specified in this
   power of attorney and accept responsibility for the supervision of the
   placement during the time the child/children is/are in the care of the
   attorney-in-fact.
   				Signature of representative of licensed child-placing agency:
   _______________________ Date: ___________

B. A power of attorney executed under this chapter is legally sufficient if the
wording of the form complies substantially with subsection A, the form is
properly completed, and the signatures of the parties are acknowledged or
verified before a notary public.

HISTORY: 2019, c. 297; 2024, c. 90.