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BRITISH COLUMBIA
REPRESENTATION AGREEMENT WITH LIMITED AND GENERAL POWERS

Made by          

of                    

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)

to                            (specify the health care needed)
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.