Continuing Power of Attorney for Personal Care

(Made in accordance with the Substitute Decision Maker Act 1992)

1.  I, ___________________________revoke any previous continuing power of attorney for personal

(print or type your full name here)

care made by me and APPOINT: ________________________________ to be my attorney(s) for

 (print or type the name of the person or persons you appoint here)

Personal care in accordance with the Substitute Decision Act 1992.

[Note: A person who provides health care, residential, social, training or support services to the person giving this power of attorney for compensation may not act as his or her attorney unless that person is also his or her spouse, partner, or relative].

1. If you have named more than one attorney and you want them to have the authority to act separately, insert the words “jointly and severally” here: ______________________________________________________________

            (this may be left blank)

1. If the person(s) I have appointed, or any one of them, cannot or will not be my attorney because of refusal, resignation, death, mental incapacity, or removal by the court, I SUBSTITUTE:

__________________________________________________________________________________________

 (this may be left blank)

to act as my attorney for personal care in the same manner and subject to the same authority as the person he or she is replacing.

1. I give my attorney(s) the AUTHORITY to make any personal care decision for me that I am mentally incapable of making for myself, including the giving or refusing of consent to any matter to which the Health Care Consent Act, 1996 applies, subject to the Substitute Decisions Act, 1992, and any instructions, conditions or restrictions contained in this form.

1. 5.         INSTRUCTIONS, CONDITIONS AND RESTRICTIONS

Attach, sign and date additional pages if required. (This part may be left blank)

1. SIGNATURE: ____________________________________  DATE: ______________________________________

(SIGN YOUR NAME IN THE PRESENCE OF TWO WITNESSES)

ADDRESS: ____________________________________________________________

(Insert your full current address here.)

1. WITNESS SIGNATURES:

(Note: The following people can not be witnesses: the attorney or his or her spouse or patner; the spouse, partner or child of the person making the document, or someone that the person treats as his or her child; a person whose property is under guardianship or who has a guardian of the person; a person under the age of 18)

Witness #1: Signature ___________________________ Print Name __________________________________

Address: __________________________________________________________________________________

____________________________________________________ Date: ________________________________

Witness #2: Signature ___________________________ Print Name __________________________________

Address: __________________________________________________________________________________

____________________________________________________ Date: ________________________________