Parents/Guardians seeking medical care assistance for their child must download this form, reading/understanding all very carefully (get help if you need it! - or email us with any questions!) - This form must be signed in the presence of a U.S. Consul at your nearest U.S. Consulate/U.S. Embassy office. Questions? Email: ICMFHope@Aol.Com
The undersigned _______________________________________(and) ________________________ of ___________________________, ___________________, is/are the parent(s) or legal guardian(s) of ___________________________________, herein referred to as "CHILD." The CHILD is in need of medical treatment which the undersigned cannot provide and is not available in ___________________________.
Therefore, the undersigned desires to place the CHILD into the Temporary custody of Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation for the express purpose of obtaining medical treatment for the CHILD.
Accordinglyh, the undersigned hereby authorize(s) and appoint(s) Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation as my/our true and lawful attorney-in-fact, for me/us, andin my/our name(s), with full power of substitution.
This Temporary Power Of Attorney conveys to Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation all parental authority, including, but not limited to:
(1) To make decisions in ICMF's sole discretion regarding legal and practical steps necessary to satisfy immigration requirements which will enbable the CHILD to temporarily immigrate to the U.S. A. for the purpose of obtaining medical treatment.
(2) To make decisions in ICMF's sole discretion regarding the manner, timing and payment of travel arrangements for the CHILD.
(3) To permit multi-media coverage regarding arrangements for the CHILD to promote the good will of International Children's Medical Foundation in obtaining medical assistance to needy children.
(4) To make necessary arrangements for medical or sugical care for the CHILD, and to give all required consent in connection with that care.
(5) To secure a Temporary Volunteer Host Family in the U.S.A. for the CHILD in the event that this becomes necessary. This Temporary Volunteer Host Family will be required to sign legal documents stating they understand this CHILD is not up for adoption and will return the CHILD anytime requested to do so, whether medical care is completed or not.
(6) To notify me/us when the best interest of my/our CHILD will be served by removal from the home of the Temporary Volunteer Host Family home and placement in a subsequent Temporary Volunteer Host Family home, acting as our agent in said removal and placement.
(7) Futher, it is understood by the undersigned that Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation has my/our permission to apply to any hospital and/or doctor for medical care treatment for my/our child.
(8) Further, it is understood that when Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation secures a hospital/doctor and/or associated medical support personnel for my/our CHILD we will be notified immediately.
Accordingly, the undersigned consents to and specifically authorizes the following:
(9) Such operations or procedures as are considered necessary or desirable in the judgment of the medical staff of the hospital rendering treatment to my/our CHILD.
(10) The administration of such anesthesia as may be considered necessary or desirable in the judgment of the medical staff of the rendering of treatment to my/our CHILD.
(11) The disposal by authorities of the hospital of any tissures which may be necessary to remove during medical treatment which would improve the condition of my/our CHILD.
(12) The admitance of medical students and other observers and to the making and use of photographs, drawings or other illustrative materials as may be deemed appropriate and desirable in accordance with the ordinary practices of the hospital/medical caregiver(s).
(13) In the event of the death of my/our CHILD, the performance of a postmortem examination by amembe of the medical staff of the hospital. Unless otherwise requested, with specific instructions in writing from parent(s) or legal guardian(s), the remains of my/our CHILD will be returned, with all organs in tact to CHILD'S home/native country for burial.
THIS AUTHROIZATION FOR MEDICAL TREATMENT/TEMPORARY POWER OF ATTORNEY is freely given and voluntarily executed by the undersigned in the best interest of the CHILD. The undersigned hereby acknowledges that Ms. Ruha'mah Stadtlander, Director of and/or International Children's Medical Foundation cannot make any specific guarantees or assurances regarding the medical results after treatment of the CHILD, and that the undersigned understands the risk involved in treatment of the CHILD.
The undersigned covenants and agrees to hold harmless any person who may act in reliace upon the authority granted y this legal instrument to Ms. Ruha'mah Stadtlander, Director of International Children's Medical Foundation. The undersigned gives and grants unto Ms. Ruha'mah Stadtlander, Director of International Childrens Medical Foundation all power to do any of the enumerated acts herein as the undersigned could do if personally present and acting in connection with these matters.
This instrument shall be effectyive as of the date of its sining, and sall remain effective until revokedinwriting, the termination of the medical teratment of the CHILD and the CHILD'S return to the the undersigned, or six months subsequent o the execution of this document, whicever comes first.
DATED this _________day of __________, 2006
PARENT(S) or LEGAL GUARDIAN(S)
Signature:______________________________________________________________________
Print:______________________________________________________________________
Signature::______________________________________________________________________
Print:______________________________________________________________________
NOTARY SEAL:
MY COMMISSION EXPIRES: ____________________________________________
SUBSCRIBED AND SWORN/AFFIRMED TO BEFORE ME THIS _____________ DAY OF _____________, 2006
NOTARY SIGNATURE/STAMP:
_______________________________________________
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