A power of attorney delegating care and custody of a student must be witnessed by a notary public and contain the following information:

1. Full name of student whose care and custody is to be transferred;
2. Date of birth of such student;
3. Full name and signature of the attorney-in-fact, to whom care and custody is to be transferred;
4. Address and telephone number of such attorney-in-fact;
5. Full name and signature of the parent or legal guardian;
6. The term for which delegation is transferred and a statement the delegation may be revoked at any time; and
7. One of the following statements:
   1. I delegate to the attorney-in-fact all of my power and authority regarding the care, custody, and property of each minor child named above including, but not limited to, the right to enroll the child in school, inspect and obtain copies of education and other records concerning the child, the right to give or withhold any consent or waiver with respect to school activities, medical and dental treatment, and any other activity, function or treatment that may concern the child. This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on, or for the child, or the termination of parental rights to the child; or
   2. I delegate to the attorney-in-fact the following specific powers and responsibilities (insert list). This delegation shall not include the power or authority to consent to marriage or adoption of the child, the performance or inducement of an abortion on, or for the child, or the termination of parental rights to the child.