Revocation of Power of Attorney for Child Care

This Revocation of Power of Attorney is made by:

Name of Parent/Guardian:

Address of Parent/Guardian:

Phone Number:

I hereby revoke the Power of Attorney for Child Care previously granted to:

Name of Attorney-in-Fact:

Address of Attorney-in-Fact:

Date Power of Attorney was Executed:

Name(s) of Child(ren):

As of the date below, all authority and powers granted under said Power of Attorney are fully revoked and terminated.

Signature of Parent/Guardian:

Date:

Witness Signature:

Date: