Form 12: Consent of Proposed Co-Decision-Maker - Alberta Human Services - Government of Alberta

Form 12: Consent of Proposed Co-Decision-Maker

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Instructions

This document tells the Court that you consent to being a co-decision-maker. You are also authorizing the review officer to conduct a criminal record check on yourself if it is needed for the review officer’s report.

Court file number: Leave blank if you do not yet have a Court file number.

Judicial Centre: Leave blank. The application will be made in the appropriate judicial centre having regard to where the assisted adult (hereafter referred to as the adult) resides.

Adult’s Full Name: fill in full legal name of the adult. Do not use nicknames or abbreviations. Use the same name all the way through the documents.

Applicant’s name: fill in full legal name of the person making the application; do not use nicknames or abbreviations. Use the same name throughout the documents. Please note that the person signing the consent may not be the same person making the application.

Please read all the sections carefully.


1. Enter the proposed Co-decision-maker(s) name(s) in the first blank and the adult’s name in the second blank.

2. You are confirming that you are over the age of 18.

3. You are confirming that you believe yourself to be a suitable person to act as co-decision-maker to the adult.

4. Check the appropriate box depending on your situation. You are confirming that you are unaware of any conflict of interest that exists or could potentially come into existence if you are appointed co-decision-maker OR you are disclosing an existing conflict of interest or potential conflict of interest. If you check the second box, please explain the situation.

5. and 6. Please read all sections carefully.

The proposed co-decision-maker must date and sign the document in the presence of a witness and have the witness sign the document and print their name.

Created:
Modified: 2015-04-21
PID: 16390

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