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Representation Agreement (S.9)


This Representation Agreement is made by me, Naveen Demo, of Apartment #3207 - 936 Happy St, North Vancouver, BC V7V3B3.
A. APPOINTMENT OF REPRESENTATIVE
I appoint my brother, Burt Hicks ("BROTHER"), of Unit 2405 - 1550 Ferney Street, West Vancouver, BC V7J 0A9 to be my Representative (the “Representative”) in accordance with the Representation Agreement Act, R.S.B.C. 1996, c. 405 as amended (the “Act”).
B. ALTERNATE REPRESENTATIVE
If Burt Hicks should be unable or unwilling to act or continue to act as my Representative, then I appoint my daughter, Cindy Lou ("ALTERNATE"), of 501 - 100 Parkway South, West Vancouver, BC V7T 1A2, to be my Representative. Cindy Lou shall confirm that Burt Hicks is unable or unwilling to act or continue to act as my Representative, by signing a Statutory Declaration to that effect.
C. APPOINTMENT OF MONITOR
A monitor is not required.
D. REVOCATION
I hereby revoke all prior Living Wills and Representation Agreements.
E. RESIGNATION
My Representative(s), including any Alternate Representative(s), may resign pursuant to s. 29(f) of the Act, upon personal delivery of a written resignation to me; or if I am then incapable, to any Alternate Representative, or, if there is no Alternate Representative, to my monitor if one is named in this Agreement, or if they are not living or capable, to the Public Guardian and Trustee.
F. EFFECTIVE DATE
In accordance with the Act, I declare that this Representation Agreement becomes effective upon, and may be exercised on the date it is executed.
G. STANDARD POWERS OF REPRESENTATIVE
I authorize my Representative to help me make decisions, or to make decisions on my behalf, about any or all of the following:
  1. do anything that my Representative considers necessary in relation to my personal care or health care, including my clothing, diet, exercise, accommodation, education, social activities and occupation; and
  2. minor health care matters, which mean routine tests and routine dental treatment, and major health care matters, which mean major surgery, receiving anesthetics, major diagnostic and investigative procedures and any care designated by regulation, as defined in the Health Care (Consent) and Care Facility (Admission) Act.
H. ADDITIONAL POWERS
I authorize my Representative to do any or all of the following:
  1. consent or refuse consent to have me physically restrained, moved, or managed, when necessary and despite my objections at that time;
  2. give consent on my behalf to all health care, even if I refuse at that time to give my consent to the health care;
  3. refuse consent on my behalf to all types of medical care, including life support care or treatment;
  4. give or refuse consent on my behalf to the kinds of health care prescribed under s. 34(2)(f) of the Health Care (Consent) and Care Facility (Admission) Act, including:
    1. electroconvulsive therapy;
    2. psychosurgery;
    3. removal of tissue from a living human body for implantation in another human body or for medical education or research;
    4. experimental health care;
    5. participation in a health care or medical research program that has not been approved by a committee that may approve medical research programs within British Columbia;
    6. any treatment, procedure or therapy that involves using aversive stimuli to induce a change in behaviour;
  5. accept or refuse a facility care proposal for my admission to a care facility;
  6. make arrangements for the temporary care, education and financial support of my minor children and my spouse and any other person or pet who is cared for and supported by me at the time of my mental infirmity; and
  7. access my personal and confidential information and documents with respect to my health.
I. EXPRESSED WISHES

The following statement of some of my beliefs and wishes is intended to supplement any specific directions or directives I have given:

If the time comes when I can no longer take part in decisions for my own future, I wish this statement to stand as an expression of my wishes while I am still capable. If a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability and my death is otherwise imminent, I wish to be allowed to die and not be kept alive by artificial means or "heroic measures". In those circumstances, I want my care to be limited to support and comfort only and I do not want any active resuscitation undertaken. I therefore ask that medication be mercifully administered to me to alleviate suffering, even though this action may hasten my death. I have carefully considered these wishes. I appreciate that any attempt to countermand this declaration may be well intentioned and, therefore, affirm that I fully understand the consequences and the implications of this declaration. I have made this declaration also to ease the emotional anguish of those who have to determine if intervention should be undertaken and to place the responsibility of the decision solely upon myself.

If my quality of life deteriorates to the point where there is no reasonable expectation of recovery or likelihood of improvement and my death is imminent or if death is not imminent but I have a grievous and irremediable medical condition, I request that, if there is an option for my Representative to consent to medical assisted death, my Representative exercise that option.
J. TERMINATION
This Agreement shall terminate upon the occurrence of any of the following:
  1. my death;
  2. the death, resignation, or incapacity of my Representative or Alternate Representative, and if there is no Representative then able to act;
  3. the Court canceling this Agreement; or
  4. if my Representative and myself are divorced or upon the termination of our marriage-like relationship and if there is no Representative then able to act; or
  5. on the effective date of my revocation of the Representation Agreement.
K. REMUNERATION
My Representative(s) or Alternate Representative(s) shall not be entitled to any remuneration for acting as my Representative, but may be reimbursed for reasonable expenses.
L. COUNTERPARTS
This Agreement may be executed in counterparts and upon each party having executed a counterpart, each counterpart shall have the same force and effect as an original instrument.
M. I, Naveen Demo have signed this Representation Agreement in the presence of the officer, whose name appears below.
TO EVIDENCE THE ABOVE, the parties have signed this Agreement.
SIGNED AND DELIVERED by,
Naveen Demo,

On ______________________,
      (month/day/year)
at Vancouver, British Columbia,

in the presence of:

RICHARD BELL
Lawyer, Bell Alliance LLP
201 – 1367 West Broadway
Vancouver, BC V6H 4A7
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____________________________________________
Naveen Demo 		 
SIGNED AND DELIVERED by,
Burt Hicks

on ______________________
      (month/day/year)
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____________________________________________
Burt Hicks
BROTHER 		 
SIGNED AND DELIVERED by,
Cindy Lou

on ______________________
      (month/day/year)
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____________________________________________
Cindy Lou
DAUGHTER 		 
 

Form 1

Representation Agreement Act

CERTIFICATE OF REPRESENTATIVE

I, Burt Hicks, of Unit 2405 - 1550 Ferney Street, West Vancouver, BC V7J 0A9, 555-555-4332, born Jun 24 1960, certify that
  1. I am named as Representative in the Representation Agreement made on ______________________, by Naveen Demo, of Apartment #3207 - 936 Happy St, North Vancouver, BC V7V3B3.

  2. I was 19 years of age or older on the date I signed the Representation Agreement referred to in this certificate.

  3. I do not provide, for compensation, personal care or health care services to the adult who made the Representation Agreement, or if I do provide the services described in this paragraph, I am a child, parent or spouse of the adult.

  4. I am not an employee of a facility in which the adult who made the Representation Agreement resides and through which he or she receives personal care or health care services, or if I am an employee described in this paragraph, I am a child, parent or spouse of the adult.

  5. I am not a witness to the Representation Agreement.

  6. I have read and understand the duties and responsibilities of a representative as set out in section 16 of the Representation Agreement Act and I have agreed to accept those duties and responsibilities. I have also read and understand section 30 of the Representation Agreement Act and have no reason to make an objection.

___________________________________________

Burt Hicks

___________________________________________

Date Signed

Form 1

Representation Agreement Act

CERTIFICATE OF ALTERNATE REPRESENTATIVE

I, Cindy Lou, of 501 - 100 Parkway South, West Vancouver, BC V7T 1A2, 555-555-7896, born Jan 31 1962, certify that
  1. I am named as Representative in the Representation Agreement made on ______________________, by Naveen Demo, of Apartment #3207 - 936 Happy St, North Vancouver, BC V7V3B3.

  2. I was 19 years of age or older on the date I signed the Representation Agreement referred to in this certificate.

  3. I do not provide, for compensation, personal care or health care services to the adult who made the Representation Agreement, or if I do provide the services described in this paragraph, I am a child, parent or spouse of the adult.

  4. I am not an employee of a facility in which the adult who made the Representation Agreement resides and through which he or she receives personal care or health care services, or if I am an employee described in this paragraph, I am a child, parent or spouse of the adult.

  5. I am not a witness to the Representation Agreement.

  6. I have read and understand the duties and responsibilities of a representative as set out in section 16 of the Representation Agreement Act and I have agreed to accept those duties and responsibilities. I have also read and understand section 30 of the Representation Agreement Act and have no reason to make an objection.

___________________________________________

Cindy Lou

___________________________________________

Date Signed