REPRESENTATION AGREEMENT WITH LIMITED AND GENERAL POWERS
1. Appointment of representative and alternate
a) I appoint of , British Columbia, as my health-care representative with the limited powers in section 7 of the Representation Agreement Act and the general powers in section 9 of the same act.
b) If my representative is unwilling to act, dies, or for any other reason is unable to act, then I appoint of , British Columbia, as my representative in his or her place.
2. Coming into effect
a) This Representation Agreement will only be in effect if I am unable to make decisions independently about my health care, personal care, or financial affairs due to lack of capacity.
b) A declaration completed by
of , British Columbia, will be sufficient proof that I am unable to make decisions independently about my health care, personal care, or financial affairs.
c) If the person named above is unable or unwilling to make a determination about my ability to make decisions independently, or cannot be reached after every reasonable effort has been made, then a written declaration signed by two physicians who are familiar with my circumstances will suffice.
3. Duties, powers, and liability of representative and alternate
I give my representative and alternate the powers set out in section 7 of the Representation Agreement Act, namely power to make decisions about —
a) my personal care;
b) routine management of my financial affairs including —
i. payment of bills;
ii. receipt and deposit of pension and other income;
iii. purchases of food, accommodation, and other services necessary for personal care; and
iv. making investments;
c) major health care and minor health care as defined in the Health-Care (Consent) and Care Facility (Admission) Act but not including the kinds of health care prescribed under section 34(2)(f) of that act;
d) obtaining legal services and instructing counsel to commence proceedings except divorce proceedings, or to continue, compromise, defend, or settle any legal proceedings;
e) accept a care facility proposal under the Health-Care (Consent) and Care Facility (Admission) Act but only if the facility is a family care home, group home for the mentally handicapped, or mental health boarding home.
I also give my representative and alternate the powers set out in section 9 of the Representation Agreement Act, namely power to —
a) physically restrain, move, or manage me, or have me physically restrained or managed when necessary and despite my objections;
b) give consent in the following circumstances
(insert if required)
(specify the health care
if I am refusing to give consent at the time that health care is needed;
c) refuse consent to
(specify health care not wanted) including life-supporting care or treatment;
d) give consent to the following kinds of health care under s.34(2)(f) of the Health-Care (Consent) and Care Facility (Admission) Act
(specify kinds of health care authorized);
e) accept a facility care proposal under the Health-Care (Consent) and Care Facility (Admission) Act for my admission to any kind of care facility;
f) make arrangements for the temporary care, education, and financial support of my minor children and any other persons cared for or supported by me;
g) do on my behalf any other thing that can be done by an attorney acting under a power of attorney that is not mentioned in sections 7 or 9 of the Representation Agreement Act.