Victorian Consolidated Legislation

Guardianship and Administration Act 1986 - SCHEDULE 4

INSTRUMENTS RELATING TO ENDURING GUARDIAN FORM 1 APPOINTMENT OF ENDURING
GUARDIAN 1. I (insert name, address and occupation of appointor), appoint
(insert name, address and occupation of proposed guardian) to be my guardian.
2. I authorise my guardian if, and only to the extent that, I subsequently
become unable by reason of a disability to make reasonable judgments in
respect of any matters relating to my person or circumstances, to exercise the
powers of a guardian under section 24 of the
Guardianship and Administration Act 1986, being all the powers that a parent
may exercise in respect of his or her child, including- · to decide where I am
to live, whether permanently or temporarily; · to decide with whom I am to
live; · to decide whether I should or should not be permitted to work and, if
so- · the nature or type of work; and · for whom I am to work; and · matters
related thereto; and · to consent to any health care that is in my best
interests; · to restrict visitors to such extent as may be necessary in my
best interests and to prohibit visits by any person if my guardian reasonably
believes that visits by that person would have an adverse effect on me.
(Delete any powers you do not wish your guardian to exercise. If you do not
delete any powers, you will be deemed to have authorised your guardian to
exercise the full powers of a guardian under section 24 of the
Guardianship and Administration Act 1986.) but subject to the following
limitations: (List any limitations you wish to place on your guardian's
powers)

3. I require my guardian to take into account the following wishes in
exercising, or in relation to the exercise of, the powers conferred by this
appointment- (State wishes to be taken into account) 4. (If applicable:) I
appoint (insert name, address and occupation of proposed alternative guardian)
to be my alternative guardian in place of, and with the same powers as, my
guardian appointed under paragraph 1 if that person is incapable of acting as
my guardian or is absent for a period. This is an appointment of an enduring
guardian made under Division 5A of Part 4 of the
Guardianship and Administration Act 1986.

........................................ (Signature of appointor)
............... (date) CERTIFICATE OF WITNESSES We (insert names, addresses
and occupations of at least 2 witnesses) certify- (a) that the appointor has
signed this instrument freely and voluntarily in our presence; and (b) that
the appointor appeared to understand the effect of this instrument.

........................................................ (Signature of witness
authorised to witness the signing of statutory declarations) ...........
(date) ......................................................... (Signature of
other witness) ........... (date) Note: An enduring guardian will be able to
make decisions on your behalf on all health care and lifestyle matters you
empower your enduring guardian to make. If you give your enduring guardian
power to make decisions about your health care, your enduring guardian will be
able to consent or withhold consent to medical or dental treatment on your
behalf. If your enduring guardian withholds consent to proposed medical or
dental treatment, a practitioner may only provide the treatment if the
practitioner believes on reasonable grounds that it is in your best interests
to do so and if the practitioner gives your enduring guardian the opportunity
to refer the matter to the Victorian Civil and Administrative Tribunal (the
Tribunal) for determination. If you wish to appoint a person who can, unless
the Tribunal otherwise determines, refuse medical treatment on your behalf,
you will need to appoint a person as your agent under the
Medical Treatment Act 1988. If you are considering appointing an agent under
the Medical Treatment Act 1988-

* you should ensure that you understand the rights and powers which an
appointment under the Medical Treatment Act 1988 confers on your agent; and

* you may wish to appoint the same person as your agent under the
Medical Treatment Act 1988 as the person you appoint as your enduring
guardian, although you may choose a different person for each role; and If you
appoint or have already appointed a person as your agent under the
Medical Treatment Act 1988 and another person as your enduring guardian-

* the decision of your agent under the Medical Treatment Act 1988 will have
priority over the decision of your enduring guardian in relation to any
proposed medical treatment; and

* your agent under the Medical Treatment Act 1988 will be able to refuse to
consent to medical treatment on your behalf in all circumstances regardless of
any consent to the treatment that your enduring guardian may give or wish to
give. ACCEPTANCE OF APPOINTMENT I, (insert name, address and occupation of
proposed guardian) accept appointment as a guardian under this instrument and
undertake to exercise the powers conferred honestly and in accordance with the
provisions of the Guardianship and Administration Act 1986.

.................................................. (Signature of proposed
guardian) ............... (date) CERTIFICATE OF WITNESSES We (insert names,
addresses and occupations of at least 2 witnesses) certify- (a) that the
proposed guardian has signed this instrument freely and voluntarily in our
presence; and (b) that the proposed guardian appeared to understand the effect
of this instrument. ........................................................
(Signature of witness authorised to witness the signing of statutory
declarations) ........... (date)
......................................................... (Signature of other
witness) ........... (date) (If applicable:) I, (insert name, address and
occupation of proposed alternative guardian) accept appointment as an
alternative guardian under this instrument and undertake to exercise the
powers conferred honestly and in accordance with the provisions of the
Guardianship and Administration Act 1986.

...................................................... (Signature of proposed
alternative guardian) ............... (date) CERTIFICATE OF WITNESSES We
(insert names, addresses and occupations of at least 2 witnesses) certify- (a)
that the proposed alternative guardian has signed this instrument freely and
voluntarily in our presence; and (b) that the proposed alternative guardian
appeared to understand the effect of this instrument.

........................................................ (Signature of witness
authorised to witness the signing of statutory declarations) ...........
(date) ......................................................... (Signature of
other witness) ........... (date) __________________

FORM 2 REVOCATION OF APPOINTMENT OF ENDURING GUARDIAN 1. I (insert name,
address and occupation of appointor), revoke the appointment of (insert name,
address and occupation of proposed guardian or alternative guardian) as my
(insert guardian or alternative guardian, as applicable). 2. This revocation
of appointment as an (insert enduring guardian or alternative enduring
guardian, as applicable) is made under Division 5A of Part 4 of the
Guardianship and Administration Act 1986.

................................................ (Signature of appointor)
........... (date) CERTIFICATE OF WITNESSES We (insert names, addresses and
occupations of at least 2 witnesses) certify- (a) that the appointor has
signed this instrument freely and voluntarily in our presence; and (b) that
the appointor appeared to understand the effect of this instrument.

........................................................ (Signature of witness
authorised to witness the signing of statutory declarations) ...........
(date) ......................................................... (Signature of
other witness) ........... (date) ---------------