Designation of Person in Parental Relation - New York

DESIGNATION OF PERSON IN PARENTAL RELATION

1. Parent, designee, and child

I, [PARENT FULL NAME], designate [DESIGNEE FULL NAME] as a person in parental relation to the child named below for the education and health matters permitted by New York General Obligations Law § 5-1551, subject to the limits in this document.

Child's full name: [________________________________]

Child's date of birth: [__/__/____]

Parent's address: [________________________________]

Parent's telephone: [________________________________]

Designee's address: [________________________________]

Designee's telephone: [________________________________]

2. Duration — choose one

☐ Thirty days or less. This designation begins on [__/__/____] and ends on [__/__/____], no later than thirty days after the parent's signature date below.

☐ More than thirty days. This designation begins on ☐ [__/__/____] or ☐ when this event occurs: [________________________________]. It ends on [__/__/____], no later than twelve months after commencement. Complete the designee consent, court-order statement, and notarial acknowledgment below.

Parent's signature date: [__/__/____]

3. Scope and limits

The designee may act in education and health matters covered by General Obligations Law § 5-1551. The following treatment, diagnosis, activities, or other matters are expressly included, if authorized by applicable law: [________________________________].

The following treatment, diagnosis, activities, or other matters are expressly excluded: [________________________________].

Other limits on the designee's authority: [________________________________].

If the spaces above are left blank, this document adds no transaction-specific inclusion or exclusion to the statutory scope.

4. Court-order statement and joint-decision consent

I state that no court order now in effect in any jurisdiction prohibits me from exercising the authority I am designating.

☐ No court order requires both parents to agree on the child's education or health decisions.

☐ A court order requires both parents to agree on those decisions. Both parents consent to this designation by signing below.

Designating parent signature: ____________________________________ Date: [__/__/____]

Second parent's printed name, if joint consent is required: [________________________________]

Second parent's consent signature, if required: ____________________________________ Date: [__/__/____]

5. Designee consent — required if duration exceeds thirty days

I, [DESIGNEE FULL NAME], consent in writing to this designation and accept its stated limits.

Designee signature: ____________________________________ Date: [__/__/____]

6. Notarial acknowledgment — required if duration exceeds thirty days

State of New York

County of [________________________________]

On [__/__/____], before me, [NOTARY NAME AND TITLE], personally appeared [PARENT SIGNER NAME(S)], who ☐ is/are personally known to me or ☐ proved identity to me on the basis of satisfactory evidence, and acknowledged signing this designation.

Notary signature: ____________________________________

Notary commission expiration: [__/__/____]

Notarial seal: [________________________________]

7. Presentation and revocation

This designation may be presented to a school, health care provider, or health plan that requires it. A parent may revoke it orally or in writing by notifying the designee or a recipient, or through another act showing specific intent to revoke. A later designation by a parent also revokes this one. A designee who receives revocation notice must promptly notify each recipient to which this designation was presented.

Recipients given a copy, if known: [________________________________]

Official law: N.Y. Gen. Oblig. Law §§ 5-1551, 5-1552, 5-1553, and 5-1554.