SAMPLE

Names of Parties

Name of the Parent/Guardian __________,

Street address for the Parent/Guardian __________,

City where the Parent/Guardian lives ___________,

Name of the state where the Parent/Guardian resides__________;

Name of the Agent _________,

Agent's complete address __________,

Information regarding the signing of this Revocation of Child Authorization

Day that the Revocation of Child Authorization will be signed ___________,

County where the Revocation of Child Authorization will be signed __________,.

State where the Revocation of Child Authorization will be signed __________,

Information regarding the Child Authorization being Revoked

The agent or caregiver listed above was given temporary power over the names of the following child __________,

Date that the Child Authorization was signed __________. (Date that the Child Authorization went into full force and effect.)

County where the Child Authorization was signed _________. (County where the Child Authorization was signed).

State where the Child Authorization was signed __________, (State where the Child Authorization was signed.)