SPECIALPOWEROFATTORNEY

KNOWALLMENBYTHESEPRESENTS:

I, (insertdetailshere),oflegalage,Filipino, withaddressat (insertdetailshere),dohereby

name,constituteandappoint(insertdetailshere),mymother,withaddressat(insertdetailshere),tobe
mytrueandlawfulattorney,forandinmyname,placeandstead,andformyownbenefit,todoallacts
necessary,towit:

1.Toperformandactasandformeinaparentalcapacitytotheabovementionedchild;

2.Togiveconsentandpermissionforanykindofmedicalcareandtreatment,andtosignany
papersthatareneededtohavetheabovementionedchildadmittedtoahospitalforsuchpurpose,oras
mayberequiredtomaintainthehealthoftheabovementionedchild.

3.Togiveconsentandpermissionforenrollmentinandadmissiontoschoolandtoresolveany
problemsthat mayarisefromschool attendance,andtosignanypapersthat are necessaryfor such
purposeorsignotherdocumentsrelatingtothechild'swelfareatschool.

4.Toperformanyactthatisnecessarytoobtainrelieforaidthatmaybenefittheabovementioned
child.

5.Performanyotheractsforsupport,health,andgeneralcareoftheabovementionedchildasmay
berequiredornecessary.

6.ThisSpecialPowerofAttorney,appointing(insert details here) asmyagentandattorneyin

factperformingandactingformeinaparentalcapacityformychild[LegalNameofChild]willbe
revokedautomaticallywithinone(1)yearfromdateofnotarizationasindicatedbelow.

7.Thatitisnotatallmyintentiontorelinquishmyfullparentalrightstotheabovementioned
child.

8. To give consent and permission and the authority to sign in my behalf to secure DSWD
clearanceallowingmychildtotravelalonetocometomeorherauntabroad;

9.Toaccompanymychildtravellingabroad

Withfullpowerandauthoritytomake,sign,seal,executeanddeliveranyandalldocuments,and
otherwritingsofwhatevernatureorkindinconnectionthereto;andingeneral,todoallotheracts,deeds,
matters,andthingswhatsoeverinfurtheranceofthepowerthusgranted;

HEREBYGIVINGANDGRANTINGuntooursaidattorneyfullpowerandauthoritytodoand
performallandeveryactrequisiteornecessarytocarryintoeffecttheforegoingauthorities,asfullytoall
intents and purposes through its authorized representatives might or could lawfully do if personally
present,withfullpowerofsubstitutionandrevocation,andherebyratifyingandconfirmingallthatthe
saidattorneysshalllawfullydoorcausetobedonebyvirtuehereof.

INWITNESSWHEREOF,Ihavehereuntosetmyhandthis_______dayof__________,2016,
at________________,Philippines.

(insertnamehere)

1
 SIGNEDINTHEPRESENCEOF:

__________________________ _________________________

ACKNOWLEDGEMENT

REPUBLICOFTHEPHILIPPINES)
CITYOFTAGUIG )S.S.

BEFOREME,aNotaryPublicforandintheabovejurisdiction,this______dayof_______________,
2016personallycomeandappeared:

NAME IDENTIFICATION DATE/PLACEOF

DOCUMENTPRESENTED ISSUE

knowntomeandtomeknowntobethesamepersonwhoexecutedtheforegoinginstrumentandthey
acknowledgedbeforemethatthesameistheirfreeandvoluntaryactanddeedandthatofthecorporation
whichtheyrepresent.

WITNESSMYHANDANDSEALonthedateandattheplacefirstabovewritten.

Doc.No.________;
PageNo.________;
BookNo._______;
Seriesof2016.