(a) The following statutory form of power of attorney to delegate parental or legal custody may be used:
STATE OF WEST VIRGINIA
STATUTORY FORM FOR POWER OF ATTORNEY TO DELEGATE PARENTAL OR LEGAL CUSTODIAN POWERS
(1) “I, ________________, certify that I am 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)
who is/are minor children.”
(2) “I designate _________________________ (Full name of designee),
_____________________________________________________________________
(Street address, city, state and zip code of designee)
______________________________________________________________________
(Home phone of designee) (Work phone of designee) as the designee of each minor child named above.”
(3) “I delegate to the designee all of my power and authority regarding the care, custody and property of each minor child named above, including but not limited to the right to enroll the child in school, 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 does 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.”
Or
(4) “I delegate to the designee the following specific powers and responsibilities
(write in):_________________________________________________________
(In the event paragraph four is completed paragraph three does not apply).
This delegation does 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.”
(5) “This power of attorney is effective for a period not to exceed one year, beginning,
_____________, ___, and ending _______, ____. I reserve the right to revoke this authority at any time."
By: ________________________________ (Parent/Legal Custodian signature)
(6) “I hereby accept my designation as designee for the minor child/children specified in this power of attorney.
By: ________________________________ (Designee signature)
State of _________________________
County of _______________________
ACKNOWLEDGMENT
Before me, the undersigned, a Notary Public, in and for said County and State on this ____day of _____________, ____, personally appeared _______________________(Name of Parent/Legal Custodian) and _______________________(Name of designee), to me known to be the identical persons who executed this instrument and acknowledged to me that each executed the same as his or her free and voluntary act and deed for the uses and purposes set forth in the instrument.
Witness my hand and official seal the day and year above written.
_________________________ (Signature of notarial officer)
_________________________ (Title and Rank)
My commission expires: ___________________”
(b) A power of attorney is legally sufficient under this article if the wording of the form substantially complies with this section, the form is properly completed, and the signatures of the parties are acknowledged.
(c) A copy of each power of attorney executed pursuant to this article shall be retained by the qualified nonprofit organization for a period of three years following the conclusion of the power of attorney. The qualified nonprofit organization shall, upon request, make these records available to the Department of Health and Human Resources.