Limited Power of Attorney (text)

LIMITED POWER OF ATTORNEY
CONSENT TO TRAVEL AND VISIT AND
RELEASE OF LIABILITY

I, the undersigned, am the natural father/natural mother/legal guardian/of _____ [name], a minor of the age of _____ [age] years. I hereby appoint [blanks for three names] as my attorneys-in-fact, jointly and severally, to take any and all action any of such deem fit with respect to the welfare and custody of said minor, including disciplining, supervising, and authorizing medical care and treatment. This limited power of attorney shall be effective commencing immediately and remaining in effect until written notice of written revocation is made to each said attorney-in-fact. This power of attorney shall be valid and effective at all times that said minor is not in my physical custody and is engaged in an activity sponsored directly or indirectly by Peoples Temple of the Disciples of Christ, also known as Peoples Temple Christian Church. In the event any of the aforesaid attorneys-in-fact are unable or unwilling to act as an attorney-in-fact, he or she may designate any other adult member of said church as attorney-in-fact in his or her stead.

I further give my consent to said minor traveling on the buses of said church and to participate in any and all transportation and visitation activities sponsored directly or indirectly by said church during the aforesaid period of time.

I further release Peoples Temple of the Disciples of Christ, its Pastor, its bus drivers, and all members of said church from any and all liability for any injuries resulting in any acts of commission or omission occurring while said minor is in any way engaged in an activity or on any trip sponsored directly or indirectly by Peoples Temple Christian Church.

(Note: use the same attorneys-in-fact as on Parental Consent form.)

[Page 2]

[Signature line]
Executed on this ____ day of _____,
197___, at _____ [Location], California.

ACKNOWLEDGMENT

STATE OF CALIFORNIA
COUNTY OF SAN FRANCISCO
UNITED STATES OF AMERICA

On _____ [date], before me, the Undersigned, a Notary Public in and for said County and State, personally appeared _______[name], known to me to be the person whose name is subscribed to the within instruments and acknowledged to me that ___ executed the same.

WITNESS MY HAND AND OFFICIAL SEAL: _____

[Pages 3 and 4 are the duplicate of pages 1 and 2]

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The forms all appear in RYMUR 89-4286-B-1-a-, with the page number(s) indicated below. The names of the minors are in alphabetical order. The date of signature also appears next to the name.