STATE OF CALIFORNIA
UNITED STATES OF AMERICA
I, _____ hereby declare:
1. I am the natural _____/ legal guardian/_____ of _____, a minor, born _____.
2. I hereby consent to said minor going to Guyana, South America, to live and be cared for their under the Guardianship or custody of _____.
I hereby appoint _____ of _____, Calif. and _____ of _____, Calif. and _____ or _____ as my attorneys-in-fact, jointly and severally, to take any and all action any of them deemed fit for the welfare of said minor. By this power of attorney, I give each of the aforesaid attorneys-in-fact the right to the care, custody, supervision, and control of said minor anywhere throughout the world, and to travel anywhere with said minor throughout the world.
Executed on this ____ day of _____, 197__, at _____, California