David Thomas Banner

3, Sussex Terrace, Hawthorn, South Australia 5062
Telephone: (+ 61 8) 8172 1222
Facsimile: (+ 61 8) 8127 9553
Contact


INSTRUCTIONS FOR ENDURING POWER OF GUARDIANSHIP
(only for residents of South Australia)


You can use this form to give me instructions for the preparation of a South Australian Enduring Power of Guardianship.

This document provides for the appointment of a guardian who has the power to make decisions about the grantor's personal circumstances if the grantor is unable to do so for himself. It covers matters such as choice of accommodation, relationships with others, holidays and other personal and "lifestyle" matters. It can also cover medical treatment if the grantor does not already have a medical agent under a Medical Power of Attorney. It "endures" and remains effective when the grantor has lost his legal capacity, i.e., soundness of mind, memory and understanding.

This form can be used to give me instructions for a single Enduring Power of Guardianship or for "mutual" or "mirror image" Powers, i.e., where spouses appoint each other (with or without additional persons) as their medical agents. Whilst the legislation is not explicit, it seems that only one guardian at a time can act. You may appoint more than one guardian, but the appointments must be "successive", i.e., the second guardian can only act if the first is unable to do so.

If I need any more information, I will contact you. Please provide as many contact details as you can.

Your e-mail address
This field is mandatory, otherwise submission of the form will fail
Your name
This field is mandatory, otherwise submission of the form will fail
YOU
(the person giving the instructions)
Full Name(s) (including surname or family name in BLOCKS)
Residential Address
Contact Address
Contact Telephone
(day and evening)
Contact Fax
Contact Email
Preferred means
INSTRUCTIONS
These instructions are for:
If for a relative, state your relationship to the grantor
If for a relative or friend, confirm that you are authorised to provide these instructions: Yes, I am authorised by the grantor(s)
The authority is in writing
The authority is verbal
Date of the authority:
GRANTOR
(the person granting the power of guardianship)
Full Name(s) (including surname or family name in BLOCKS)
Full Address
Occupation(s) or description(s)
GUARDIAN 1
(the first person whom you wish to appoint as your guardian)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
GUARDIAN 2
(the second person [if any] whom you wish to appoint as your guardian)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
GUARDIAN 3
(the third person [if any] whom you wish to appoint as your guardian)
Full Name (including surname or family name in BLOCKS)
Full Address
Occupation or description
Relationship (if any) to grantor
CONDITIONS
You can impose certain conditions on the exercise of the guardian's powers. These are some conditions you may wish to consider.

Refusal of artificial life-sustaining measures when you are in the terminal phase of a terminal illness or in a persistent vegetative state

Refusal of certain drugs or medications - please specify:

Refusal of certain surgical procedures - please specify:

Refusal of certain non-surgical procedures, e.g., blood transfusions - please specify:

Other - please specify:

CUSTODY
Where do you want the original Enduring Power of Guardianship to be held?

If "Other", please specify:

EXECUTION The Grantor and the Guardian(s) must sign the Enduring Power of Guardianship in the presence of a Commissioner for Taking Affidavits in the Supreme Court of South Australia (usually a solicitor); a Justice of The Peace for South Australia; a proclaimed manager; a proclaimed member of the police force; or a member of the clergy.


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THANK YOU FOR YOUR INSTRUCTIONS!

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