POWER OF ATTORNEY
Click Here For A Downloadable PDF Copy Of This Power Of Attorney
In many instances care “is” available in the
child’s country but the parents simply “want” the child to be treated
abroad. We can “only” help in those cases where there is “no” medical
care available in the child’s native country.
All forms and other correspondence must be in English.
This Power Of Attorney form gives International Children's Medical
Foundation the required needed authorization to seek medical care for their
child. This form must be printed out, in it's entirety, with no changes
made and presented to a US Notary at your local area US Consulate or US
Questions? Email: ICMFHOPE@Aol.Com
POWER OF ATTORNEY
___________________________________________, is/are the parent(s) or
legal guardian(s) of
___________________________________________, herein referred to as
The CHILD is in need of medical treatment which the undersigned
cannot provide and is not available in (name of your country).
Therefore, the undersigned desires to place the CHILD into the
Temporary custody of Ms. Ruha'mah Stadtlander, Director of International
Children's Medical Foundation (ICMF) for the express purpose of obtaining medical treatment for the CHILD.
Accordingly, 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, and/in 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 (ICMF) 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
enable 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
(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) Further, 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
(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.
1. The admittance 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 a member 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 AUTHORIZATION 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 Children's 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 effective as of the date of its signing, and
shall remain effective until revoked in writing, the termination of the
medical treatment of the CHILD and the CHILD'S return to the the undersigned, or six months
subsequent or the execution of this document, whichever comes first.
DATED this ________day of __________, 200__
PARENT(S) or LEGAL GUARDIAN(S)
MY COMMISSION EXPIRES:
SUBSCRIBED AND SWORN/AFFIRMED TO BEFORE ME THIS:
_______ DAY OF _____________, 200__