I Don't know about your state, but this is one we used in MD from last year, done by an Attorney
APPOINTMENT OF HEALTH CARE AGENT
FOR CHILDREN BY
********** AND *********
(1) We, **************, residing at **************, appoint the following individual(s) as our agent(s) to make health care decisions for our children, ***********, age **, and *****, age **.
*********
*********
**********
(2) Individually or jointly my agent(s) have full power and authority to make health care decisions for our children, including the power to:
a. Request, receive, and review any information, oral or written, regarding their physical or mental health, including, but not limited to, medical and hospital records, and consent to disclosure of this information;
b. Employ and discharge health care providers;
c. Authorize their admission to or discharge from (including transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and
d. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures.
(3) The authority of our agent(s) is not subject to any limitations.
(4) Our agent(s)' authority is operative immediately and terminates on *******, 200*
(5) Our agent(s) is/are to make health care decisions for our children based on the health care instructions we give in this document and on our wishes as otherwise known to my agent. If our wishes are unknown or unclear, my agent(s) is/are to make health care decisions for our children in accordance with their best interest, to be determined by our agent(s) after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment.
(6) Our agents shall not be liable for the costs of care based solely on this authorization. By signing below, we indicate that we are emotionally and mentally competent to make this appointment of health care agents and that we understand its purpose and effect
________________________ ____________________________________
Date *************
____________________________________
Address
____________________________________
________________________ ____________________________________
Date **************
____________________________________
Address
____________________________________
Witnesses
The declarant signed or acknowledged signing this appointment of a health care agent in my presence and based upon my personal observation appears to be a competent individual.
________________________ ____________________________________
Date Address
____________________________________
________________________ ____________________________________
Date Address
____________________________________
STATE OF:
COUNTY OF:
The undersigned, being a notary public in and for the state and county aforesaid, hereby certify that on this _____ day of 200*, personally appeared ********* and *********, a known to me to be, or proven to be, the persons whose names appear above, and they did execute the above document for the purposes stated therein acknowledging this to be their act.
____________________________________
Notary Public
My Commission Expires:
that my sister and her husband are giving me permission to take him out of the country on the 
