1 Information About You

You may fill out this form on your own behalf or you may act on behalf of another person. If you are acting on behalf of another person, please attach proof of your authority to act on that person’s behalf.

Instructions to Public Bodies: Always include this page. Modify or delete sections 2 through 5 as appropriate.

☐ I am acting on my own behalf

☐ I am acting on behalf of another individual who is

☐ a minor who is incapable of acting on her/his own behalf

☐ an adult for whom I am

☐ a committee appointed under the Patients Property Act;

☐ a person acting under a power of attorney;

☐ a litigation guardian;

☐ a representative acting under a representation agreement.

☐ a deceased adult for whom I am

☐ a committee appointed under the Patients Property Act;

☐ a personal representative as defined in the Interpretation Act;

☐ the nearest relative willing and able to act, as set out in the regulation to the Freedom of Information and Protection of Privacy Act.

☐ a deceased minor for whom

☐ I am a personal representative as defined in the Interpretation Act;

☐ I was a guardian immediately before her/his death;

☐ I am the nearest relative willing and able to act, as set out in the regulation to the Freedom of Information and Protection of Privacy Act.

Information about me:

☐ Ms ☐ Mr ☐ Other	Last name	First Name

Information about the person on whose behalf I am acting, if applicable:

☐ Ms ☐ Mr ☐ Other	Last name	First Name

☐ I have attached proof of my authority to act on this person’s behalf.

Attach and list any supporting documentation

The consent below is effective on the date shown below and shall remain in effect

☐ until Date consent expires, if applicable, or

☐ indefinitely, unless I revoke it earlier, in writing.

Full Name	Signature	Date

The collection of personal information provided on this form is authorized under section 26 of the Freedom of Information and Protection of Privacy Act for the purpose(s) set out below. Should you have any questions about the collection of this personal information please contact: Position title, address and phone number of an officer or employee of the public body who can answer questions about the collection

2 Consent for Collection of Personal Information

A public body may only collect personal information for authorized purposes. In the limited cases set out below, a public body can collect personal information with your consent.

Instructions to Public Bodies: Include this section where the collection of personal information is done only for the purpose of notifying other B.C. public bodies and/or Canadian federal government institutions of a name change, change of personal contact information or a death. Consent is not an authority for collection in any other circumstance.

Personal Contact Information

To allow the following B.C. public bodies and/or Canadian federal government institutions to record or update my personal contact information:

Provide names of B.C. public bodies and/or Canadian federal government institutions to receive change(s) to contact information,

☐ I consent to the collection of the following personal contact information:

Address	Telephone Number	E-mail address

Other personal contact information: List the other personal contact information to be collected

AND / OR

Change of Name

To allow the following B.C public bodies and/or Canadian federal government institutions to record or update my name:

Provide names of B.C. public bodies and/or Canadian federal government institutions to receive name change information,

☐ I consent to the collection of the following personal information about the change of my name from State old name to State new name :

List the personal information to be collected (e.g., date of birth, location of birth, date of death, location of death).

by Name of public body.

☐ I have attached the following proof of my name change

Attach and list any supporting documentation that shows every name change (e.g., current and/or previous marriage certificate, legal change of name certificate, divorce certificate, birth certificate or certificate of adoption showing a previous surname)

Notification of Death

For the purpose of allowing the following B.C. public bodies and/or Canadian federal government institutions to receive notification of a death, so that any benefits or services relating to the deceased may be provided or cancelled, as applicable:

Provide names of B.C. public bodies and/or Canadian federal government institutions to receive death notification,

☐ I consent to the collection of the following personal information about the deceased individual on whose behalf I am authorized to act:

List the personal information to be collected (e.g., name, date of death, location of death)

by Name of public body.

☐ I have attached the following proof of death.

Attach and list any supporting documentation (e.g., death certificate)

3 Authorization for Indirect Collection of Personal Information

A public body may only collect personal information directly from you, except in limited circumstances set out in the Act, including where you provide authorization to collect it from another source.

Instructions to Public Bodies: Include this section where the indirect collection of an individual’s personal information is from a source not otherwise authorized under the Act.

☐ I authorize the indirect collection of the following personal information:

List the personal information to be collected,

by Name of public body,

from Name the entities from which and/or individuals from whom personal information will be collected.

4 Consent for Use of Personal Information

A public body may only use personal information in limited circumstances set out in the Act, including where you provide your consent.

Instructions to Public Bodies: Include this section where an individual’s personal information will be used for a purpose that is different from the original purpose for collection and from any purposes consistent with the original purpose.

☐ I consent to the use of the following personal information: Describe the personal information

by Name of public body,

for the following purpose(s): Describe how the personal information will be used.

5 Consent for Disclosure inside or outside of Canada, Storage of Personal Information Outside of Canada and Access to Personal Information from outside Canada

A public body may only disclose personal information inside or outside of Canada, store personal information outside of Canada or allow access to personal information from outside Canada, in limited circumstances set out in the Act, including where you provide your consent.

Instructions to Public Bodies: Include this section where (a) the disclosure of an individual’s personal information is made inside or outside Canada and the disclosure is not otherwise authorized under the Act and/or (b) personal information is to be stored in or accessed from a jurisdiction outside of Canada.

I consent to

☐ the disclosure inside or outside Canada

☐ the storage outside Canada

☐ the access from outside Canada

of the following personal information: Describe the personal information

by Name of public body, to/by:

Name the entities to which and/or individuals to whom personal information will be disclosed (as applicable)	Name the entities or individual which will access the personal information from outside Canada (as applicable)	Name the entities or individual which will store the personal information outside Canada (as applicable)	Describe the purpose(s) for the disclosure, storage and/or access (as applicable)

THIS SECTION IS ONLY NECESSARY WHERE IT IS POSSIBLE TO SPECIFY JURISDICTION OF DISCLOSURE/STORAGE/ACCESS:
☐ I understand that my personal information (described above) will be disclosed to the following jurisdiction(s) (specify locations), and /or stored in the following jurisdictions (specify locations) and/or accessed from the following jurisdictions (specify locations).