VA Code § 20-167 (2021)
2021 Code of Virginia|Title 20 - Domestic Relations|Chapter 10 - Power of Attorney to Delegate Parental or Legal Custodial Powers|§ 20-167. Statutory form for power of attorney to delegate parental or legal custodial powers

A. A power of attorney to delegate parental or legal authority executed pursuant to this chapter shall be substantially as follows:POWER OF ATTORNEY TO DELEGATE PARENTAL OR LEGAL CUSTODIAL POWERS1. I/We certify that I/we am/are 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: __________2. I/We designate ____________________ (insert full name, address, and phone number of designated attorney-in-fact) as the attorney-in-fact of each child listed above.3. I/We delegate to the attorney-in-fact all of my/our power and authority regarding the care, custody, and property of each minor child named above, including the right to enroll the child in school, the right to 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 shall 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. I/We understand that this power of attorney shall not operate to change or modify any parental or legal rights, obligations, or authority established by an existing court order or deprive a parent or legal custodian of any parental or legal rights, obligations, or authority regarding the custody, visitation, or support of any child under Title 20 of the Code of Virginia, and I/we understand that I/we shall continue to be bound by any obligations in such order. By my/our signature below, I/we hereby certify that I/we am/are not executing this power of attorney for any unlawful purpose or for the primary purpose of enrolling my/our child/children in a school for the sole purpose of participating in the academic or interscholastic athletics programs provided by that school.OR3. I/We delegate to the attorney-in-fact the following specific powers and responsibilities:__________________________________________________________________________________________________________________________________________.This delegation shall 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. I/We understand that this power of attorney shall not operate to change or modify any parental or legal rights, obligations, or authority established by an existing court order or deprive a parent or legal custodian of any parental or legal rights, obligations, or authority regarding the custody, visitation, or support of any child under Title 20 of the Code of Virginia, and I/we understand that I/we shall continue to be bound by any obligations in such order. By my/our signature below, I/we hereby certify that I/we am/are not executing this power of attorney for any unlawful purpose or for the primary purpose of enrolling my/our child/children in a school for the sole purpose of participating in the academic or interscholastic athletics programs provided by that school.4. This power of attorney is effective for a period not to exceed 180 days, beginning __________ (insert date) and ending __________ (insert date). I/We reserve the right to revoke this authority at any time.OR4. I/We am/are a service member, as defined by § 20-166 of the Code of Virginia, and am/are on, or am/are scheduled to be on, active duty for a period that is set to last longer than 180 days. This power of attorney is effective for a period not to exceed the period of active duty plus 30 days, beginning __________ (insert date) and ending __________ (insert date). I/We reserve the right to revoke this authority at any time.Signature(s) of parent/legal custodian: __________________________ Date: _______5. I hereby accept my designation as attorney-in-fact for the minor child/children specified in this power of attorney and agree to act at all times in the best interests of the child/children specified herein and within the limits of the powers delegated to me. I understand that this power of attorney does not change or modify any parental or legal rights, obligations, or authority established by an existing court order or deprive a parent or legal custodian of any parental or legal rights, obligations, or authority regarding the custody, visitation, or support of the child/children specified herein. By my signature below, I affirm that I have received notice of any existing court order regarding the custody, visitation, or support of the child/children and agree to honor the rights of a parent or legal custodian of the child/children as specified in such order.Signature of attorney-in-fact: _________________________________ Date: ________6. I, ___________________ (insert name of representative of licensed child-placing agency), on behalf of __________________ (insert name of licensed child-placing agency), hereby approve the designation of the aforementioned attorney-in-fact for the minor child/children specified in this power of attorney and accept responsibility for the supervision of the placement during the time the child/children is/are in the care of the attorney-in-fact.Signature of representative of licensed child-placing agency: _________________ Date: ________B. A power of attorney executed under this chapter is legally sufficient if the wording of the form complies substantially with subsection A, the form is properly completed, and the signatures of the parties are acknowledged or verified before a notary public.2019, c. 297.