AB581,10,44
Agent's telephone number(s) ....
AB581,10,55
Agent's e-mail address ....
AB581,10,66
Relationship of agent to child(ren) ....
AB581,10,77
The parental power I am delegating is as follows:
AB581,10,109
(
Check if you want to delegate full parental power regarding the care and
10custody of the child(ren) named above.)
AB581,10,1211
.... Full parental power regarding the care and custody of the child(ren) named
12above
AB581,10,1514
(
Check each subject over which you want to delegate your parental power
15regarding the child(ren) named above.)
AB581,10,1616
.... The power to consent to all health care; or
AB581,10,1717
.... The power to consent to only the following health care:
AB581,10,1918
.... Ordinary or routine health care, excluding major surgical procedures,
19extraordinary procedures, and experimental treatment
AB581,10,2020
.... Emergency blood transfusion
AB581,10,2121
.... Dental care
AB581,10,2222
.... Disclosure of health information about the child(ren)
AB581,10,2323
.... The power to consent to educational and vocational services
AB581,10,2424
.... The power to consent to the employment of the child(ren)
AB581,11,2
1.... The power to consent to the disclosure of confidential information, other
2than health information, about the child(ren)
AB581,11,33
.... The power to provide for the care and custody of the child(ren)
AB581,11,54
.... The power to consent to the child(ren) obtaining a motor vehicle operator's
5license
AB581,11,66
.... The power to travel with the child(ren) outside the state of Wisconsin
AB581,11,77
.... The power to obtain substitute care, such as child care, for the child(ren)
AB581,11,118
.... Other specifically delegated powers or limits on delegated powers (
Fill in the
9following space or attach a separate sheet describing any other specific powers that
10you wish to delegate or any limits that you wish to place on the powers you are
11delegating.) ....
AB581,11,1412
This delegation of parental powers does not deprive a custodial or noncustodial
13parent of any of his or her powers regarding the care and custody of the child,
14whether granted by court order or force of law.
AB581,11,2115
THIS DOCUMENT MAY NOT BE USED TO DELEGATE THE POWER TO
16CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN), THE
17PERFORMANCE OR INDUCEMENT OF AN ABORTION ON OR FOR THE
18CHILD(REN), THE TERMINATION OF PARENTAL RIGHTS TO THE
19CHILD(REN), THE ENLISTMENT OF THE CHILD(REN) IN THE U.S. ARMED
20FORCES OR TO PLACE THE CHILD(REN) IN A FOSTER HOME, GROUP HOME,
21OR INPATIENT TREATMENT FACILITY.
AB581,11,2322
EFFECTIVE DATE AND TERM
23
OF THIS DELEGATION
AB581,12,824
This Power of Attorney takes effect on .... and will remain in effect until .... If
25no termination date is given
or if the termination date given is more than one year
1after the effective date of this Power of Attorney, this Power of Attorney will remain
2in effect for a period of one year after the effective date, but no longer.
If the
3termination date given is more than one year after the effective date of this Power
4of Attorney, this Power of Attorney must be approved by the juvenile court. This
5Power of Attorney may be revoked in writing at any time by a parent who has legal
6custody of the child(ren) and such a revocation invalidates the delegation of parental
7powers made by this Power of Attorney, except with respect to acts already taken in
8reliance on this Power of Attorney.
AB581,12,99
SIGNATURE(S) OF PARENT(S)
AB581,12,1010
Signature of parent ....
Date ....
AB581,12,1111
Parent's name printed ....
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Parent's address ....
AB581,12,1313
Parent's telephone number ....
AB581,12,1414
Parent's e-mail address ....
AB581,12,1515
Signature of parent ....
Date ....
AB581,12,1616
Parent's name printed ....
AB581,12,1717
Parent's address ....
AB581,12,1818
Parent's telephone number ....
AB581,12,1919
Parent's e-mail address ....
AB581,12,2020
WITNESSING OF SIGNATURE(S) (OPTIONAL)
AB581,12,2121
State of ....
AB581,12,2222
County of ....
AB581,12,2323
This document was signed before me on .... (date) by .... (name(s) of parent(s)).
AB581,12,2424
Signature of notary ....
AB581,12,2525
My commission expires: ....
AB581,13,1
1STATEMENT OF AGENT
AB581,13,82
I, .... (name and address of agent), understand that .... (name(s) of parent(s)) has
3(have) delegated to me the powers specified in this Power of Attorney regarding the
4care and custody of .... (name(s) of child(ren)). I further understand that this Power
5of Attorney may be revoked in writing at any time by a parent who has legal custody
6of .... (name(s) of child(ren)). I hereby declare that I have read this Power of Attorney,
7understand the powers delegated to me by this Power of Attorney, am fit, willing, and
8able to undertake those powers, and accept those powers.
AB581,13,99
Agent's signature ....
Date ....
AB581,13,1211
(
Here the parent(s) may indicate where they may be located during the term of
12the Power of Attorney if different from the address(es) set forth above.)
AB581,13,1313
.... I can be located at:
AB581,13,1414
Address(es) ....
AB581,13,1515
Telephone number(s) ....
AB581,13,1616
E-mail address(es) ....
AB581,13,1717
.... Or, by contacting:
AB581,13,1919
Address ....
AB581,13,2020
Telephone number ....
AB581,13,2121
E-mail address ....
AB581,13,2222
.... Or, I cannot be located
AB581,11
23Section
11. 948.25 of the statutes is created to read:
AB581,14,3
24948.25 Unauthorized interstate placements of children. (1) Any person
25who sends a child out of this state, brings a child into this state, or causes a child to
1be sent out of this state or brought into this state for the purpose of permanently
2transferring physical custody of the child to a person who is not a relative of the child
3is guilty of a Class A misdemeanor.
AB581,14,4
4(2) Subsection (1) does not apply to any of the following:
AB581,14,55
(a) A placement of a child that is authorized under s. 48.98, 48.988, or 48.99.
AB581,14,76
(b) A placement of a child that is approved by a court of competent jurisdiction
7of the sending state or receiving state.
AB581,12
8Section
12.
Nonstatutory provisions.
AB581,14,129
(1)
Study of adoption disruption and dissolution. The joint legislative council
10is requested to study adoption disruption and dissolution in this state. If the joint
11legislative council undertakes such a study, the joint legislative council shall do all
12of the following:
AB581,14,1513
(a) Study the extent of adoption disruption and dissolution in this state and the
14efforts by the department of children and families, counties, and child welfare
15agencies to prevent such disruption and dissolution.
AB581,14,1616
(b) Recommend legislation to accomplish all of the following:
AB581,14,17
171. Define adoption disruption and adoption dissolution.
AB581,14,18
182. Prevent adoption disruption and adoption dissolution in this state.
AB581,14,22
193. Require the department of children and families, county departments of
20human services or social services that are authorized to place children for adoption,
21and child welfare agencies that are licensed to place children for adoption to track
22and report on disrupted or dissolved adoptions.
AB581,14,2423
(c) Consider legislative options to prepare prospective adoptive parents for
24adoption and to support adoptive parents after an adoption.
AB581,15,2
1(d) Submit its findings, conclusions, and recommendations to the 2015
2legislature when it commences.
AB581,13
3Section
13.
Initial applicability.
AB581,15,74
(1)
Advertising related to adoption or other permanent physical placements
5of a child. The treatment of section 48.825 (1) (a), (2) (a), (b), and (c), and (3) (a) and
6(e) of the statutes first applies to advertising placed or posted on the effective date
7of this subsection.