AB30-ASA1,12,2424 Name, address, and date of birth of child ....
AB30-ASA1,12,2525 Name, address, and date of birth of child ....
AB30-ASA1,13,1
1Name, address, and date of birth of child ....
AB30-ASA1,13,22 DELEGATION OF POWER TO AGENT
AB30-ASA1,13,43 I, .... (name and address of parent), state that I have legal custody of the
4child(ren) named above. (Only a parent who has legal custody may use this form.)
AB30-ASA1,13,55 I delegate my parental power to:
AB30-ASA1,13,66 Name of agent ....
AB30-ASA1,13,77 Agent's address ....
AB30-ASA1,13,88 Agent's telephone number(s) ....
AB30-ASA1,13,99 Agent's e-mail address ....
AB30-ASA1,13,1010 Relationship of agent to child(ren) ....
AB30-ASA1,13,1111 The parental power I am delegating is as follows:
AB30-ASA1,13,1413 (Check if you want to delegate full parental power regarding the care and
14custody of the child(ren) names above.
)
AB30-ASA1,13,1615 .... Full parental power regarding the care and custody of the child(ren) named
16above
AB30-ASA1,13,1717 partial
AB30-ASA1,13,1918 (Check each subject over which you want to delegate your parental power
19regarding the child(ren) names above.
)
AB30-ASA1,13,2020 .... The power to consent to all health care; or
AB30-ASA1,13,2121 .... The power to consent to only the following health care:
AB30-ASA1,13,2322 .... Ordinary or routine health care, excluding major surgical procedures,
23extraordinary procedures, and experimental treatment
AB30-ASA1,13,2424 .... Emergency blood transfusion
AB30-ASA1,13,2525 .... Dental care
AB30-ASA1,14,1
1.... Disclosure of health information about the child(ren)
AB30-ASA1,14,22 .... The power to consent to educational and vocational services
AB30-ASA1,14,33 .... The power to consent to the employment of the child(ren)
AB30-ASA1,14,54 .... The power to consent to the disclosure of confidential information, other
5than health information, about the child(ren)
AB30-ASA1,14,66 .... The power to provide for the care and custody of the child(ren)
AB30-ASA1,14,87 .... The power to consent to the child(ren) obtaining a motor vehicle operator's
8license
AB30-ASA1,14,99 .... The power to travel with the child(ren) outside the state of Wisconsin
AB30-ASA1,14,1010 .... The power to obtain substitute care, such as child care, for the child(ren)
AB30-ASA1,14,1411 .... Other specifically delegated powers or limits on delegated powers (Fill in the
12following space or attach a separate sheet describing any other specific powers that
13you wish to delegate or any limits that you wish to place on the powers you are
14delegating.
) ....
AB30-ASA1,14,1715 This delegation of parental powers does not deprive a custodial or noncustodial
16parent of any of his or her powers regarding the care and custody of the child,
17whether granted by court order or force of law.
AB30-ASA1,14,2418 THIS DOCUMENT MAY NOT BE USED TO DELEGATE THE POWER TO
19CONSENT TO THE MARRIAGE OR ADOPTION OF THE CHILD(REN), THE
20PERFORMANCE OR INDUCEMENT OF AN ABORTION ON OR FOR THE
21CHILD(REN), THE TERMINATION OF PARENTAL RIGHTS TO THE
22CHILD(REN), THE ENLISTMENT OF THE CHILD(REN) IN THE U.S. ARMED
23FORCES OR TO PLACE THE CHILD(REN) IN A FOSTER HOME, GROUP HOME,
24OR INPATIENT TREATMENT FACILITY.
AB30-ASA1,14,2525 EFFECTIVE DATE AND TERM OF THIS DELEGATION
AB30-ASA1,15,8
1This Power of Attorney takes effect on .... and will remain in effect until .... If
2no termination date is given or if the termination date given is more than one year
3after the effective date of this Power of Attorney, this Power of Attorney will remain
4in effect for a period of one year after the effective date, but no longer. This Power
5of Attorney may be revoked in writing at any time by a parent who has legal custody
6of the child(ren) and such a revocation invalidates the delegation of parental powers
7made by this Power of Attorney, except with respect to acts already taken in reliance
8on this Power of Attorney.
AB30-ASA1,15,99 SIGNATURE(S) OF PARENT(S)
AB30-ASA1,15,1010 Signature of parent .... Date ....
AB30-ASA1,15,1111 Parent's name printed ....
AB30-ASA1,15,1212 Parent's address ....
AB30-ASA1,15,1313 Parent's telephone number ....
AB30-ASA1,15,1414 Parent's e-mail address ....
AB30-ASA1,15,1515 Signature of parent .... Date ....
AB30-ASA1,15,1616 Parent's name printed ....
AB30-ASA1,15,1717 Parent's address ....
AB30-ASA1,15,1818 Parent's telephone number ....
AB30-ASA1,15,1919 Parent's e-mail address ....
AB30-ASA1,15,2020 WITNESSING OF SIGNATURE(S) (OPTIONAL)
AB30-ASA1,15,2121 State of ....
AB30-ASA1,15,2222 County of ....
AB30-ASA1,15,2323 This document was signed before me on .... (date) by .... (name(s) of parent(s)).
AB30-ASA1,15,2424 Signature of notary ....
AB30-ASA1,15,2525 My commission expires: ....
AB30-ASA1,16,1
1STATEMENT OF AGENT
AB30-ASA1,16,82 I, .... (name and address of agent), understand that .... (name(s) of parent(s)) has
3(have) delegated to me the powers specified in this Power of Attorney regarding the
4care and custody of .... (name(s) of child(ren)). I further understand that this Power
5of Attorney may be revoked in writing at any time by a parent who has legal custody
6of .... (name(s) of child(ren)). I hereby declare that I have read this Power of Attorney,
7understand the powers delegated to me by this Power of Attorney, am fit, willing, and
8able to undertake those powers, and accept those powers.
AB30-ASA1,16,99 Agent's signature .... Date ....
AB30-ASA1,16,1010 APPENDIX
AB30-ASA1,16,1211 (Here the parent(s) may indicate where they may be located during the term of
12the Power of Attorney if different from the address(es) set forth above.
)
AB30-ASA1,16,1313 .... I can be located at:
AB30-ASA1,16,1414 Address(es) ....
AB30-ASA1,16,1515 Telephone number(s) ....
AB30-ASA1,16,1616 E-mail address(es) ....
AB30-ASA1,16,1717 .... Or, by contacting:
AB30-ASA1,16,1818 Name ....
AB30-ASA1,16,1919 Address ....
AB30-ASA1,16,2020 Telephone number ....
AB30-ASA1,16,2121 E-mail address ....
AB30-ASA1,16,2222 .... Or, I cannot be located
AB30-ASA1,16,23 23(3) (a) In this subsection:
AB30-ASA1,16,2524 1. "Agent" means a person to whom delegation of the care and custody of a child
25under this section is facilitated by an organization.
AB30-ASA1,17,2
12. "Organization" means an organization that facilitates delegations of the care
2and custody of children under this section.
AB30-ASA1,17,43 (b) The department shall promulgate rules to implement this section. Those
4rules shall include rules establishing all of the following:
AB30-ASA1,17,85 1. Training requirements for the staff of an organization, including training in
6identifying children who have been abused or neglected and the laws and procedures
7under s. 48.981 governing the reporting of suspected or threatened child abuse or
8neglect.
AB30-ASA1,17,179 2. Screening and assessment requirements for a proposed agent, including a
10screening of the personal characteristics, health, and finances of the proposed agent
11and of the physical environment and safety of the proposed agent's home and, based
12on that screening, an assessment of the proposed agent's fitness to provide for the
13care and custody of the child and ability to meet the child's needs. The rules
14promulgated under this subdivision shall prohibit an organization from facilitating
15a delegation of the care and custody of a child to a proposed agent unless the proposed
16agent is fit to provide for the care and custody of the child and able to meet the child's
17needs.
AB30-ASA1,17,1918 3. Training requirements for an agent, including the training described in
19subd. 1. and training in the expectations of an agent specified in subd. 4.
AB30-ASA1,18,220 4. The expectations of an agent with respect to the care and custody of the child,
21including expectations relating to the care, nurturing, protection, training,
22guidance, and discipline of the child; the provision of food, shelter, education, and
23health care for the child; cooperation with the child's parents in coparenting the
24child; and cooperation with the organization in facilitating visitation and other

1communications with the child's parents and in otherwise complying with the
2expectations of the organization.
AB30-ASA1,18,53 5. A requirement that an organization regularly monitor an agent and the child
4whose care and custody is delegated to the agent and maintain communications with
5the child's parents.
AB30-ASA1, s. 21 6Section 21. 48.981 (2) (a) (intro.) of the statutes is amended to read:
AB30-ASA1,18,127 48.981 (2) (a) (intro.) Any of the following persons who has reasonable cause
8to suspect that a child seen by the person in the course of professional duties has been
9abused or neglected or who has reason to believe that a child seen by the person in
10the course of professional duties has been threatened with abuse or neglect and that
11abuse or neglect of the child will occur shall, except as provided under sub. subs. (2m)
12and (2r), report as provided in sub. (3):
AB30-ASA1, s. 22 13Section 22. 48.981 (2) (b) of the statutes is amended to read:
AB30-ASA1,18,1914 48.981 (2) (b) A court-appointed special advocate who has reasonable cause to
15suspect that a child seen in the course of activities under s. 48.236 (3) has been
16abused or neglected or who has reason to believe that a child seen in the course of
17those activities has been threatened with abuse and neglect and that abuse or neglect
18of the child will occur shall, except as provided in sub. subs. (2m) and (2r), report as
19provided in sub. (3).
AB30-ASA1, s. 23 20Section 23. 48.981 (2) (bm) 1. (intro.) of the statutes is amended to read:
AB30-ASA1,18,2421 48.981 (2) (bm) 1. (intro.) Except as provided in subd. 3. and sub. subs. (2m) and
22(2r)
, a member of the clergy shall report as provided in sub. (3) if the member of the
23clergy has reasonable cause to suspect that a child seen by the member of the clergy
24in the course of his or her professional duties:
AB30-ASA1, s. 24 25Section 24. 48.981 (2) (bm) 2. (intro.) of the statutes is amended to read:
AB30-ASA1,19,4
148.981 (2) (bm) 2. (intro.) Except as provided in subd. 3. and sub. subs. (2m) and
2(2r)
, a member of the clergy shall report as provided in sub. (3) if the member of the
3clergy has reasonable cause, based on observations made or information that he or
4she receives, to suspect that a member of the clergy has done any of the following:
AB30-ASA1, s. 25 5Section 25. 48.981 (2m) (title) of the statutes is amended to read:
AB30-ASA1,19,66 48.981 (2m) (title) Exception to reporting requirement; health care services.
AB30-ASA1, s. 26 7Section 26. 48.981 (2r) of the statutes is created to read:
AB30-ASA1,19,148 48.981 (2r) Exception to reporting requirement; person delegated parental
9powers.
A person delegated care and custody of a child under s. 48.979 is not required
10to report as provided in sub. (3) any suspected or threatened abuse or neglect of the
11child as required under sub. (2) (a), (b), or (bm) or (2m) (d) or (e). Such a person who
12has reason to suspect that the child has been abused or neglected or who has reason
13to believe that the child has been threatened with abuse or neglect and that abuse
14or neglect of the child will occur may report as provided in sub. (3).
AB30-ASA1, s. 27 15Section 27. Nonstatutory provisions.
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