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Application for Consideration of an External Agency Collaboration

Supplemental Student Services by Non-Regulated Professionals/Paraprofessionals

This form is to be completed by an External Agency as application for consideration of the provision of program/services within schools of the Kawartha Pine Ridge District School Board. This form is to be submitted to the Supplemental Student Services Committee in keeping with Administrative Regulation ES - 3.8.3.

Part A: External Agency Information

Agency provides service in:
 
Validation of agency status
 

Part B: Program / Service Description

Languages the program/service is delivered in:
 

Part C: Staff Qualifications and Responsibilities

Part D: Supervision Schedule

Part E: Informed Consent

  1. In cases where a student is withdrawn from regular classroom services, please outline procedures for obtaining informed consent from adult learners, and from parents of student under 18 years of age. A blank copy of consent documentation is also required.

  2. In cases of whole classroom support, please attach a sample letter informing parent(s)/legal guardian(s) or adult learner(18 years) of the services to be provided and consent form where applicable.
Please check appropriate box
 

Part F: Space Resources and Materials

It is understood that any needs for space and material resources by the External Agency must be clearly articulated and approved by the KPRDSB. Space for KPRDSB staff to execute their duties will be ensured prior to offering space to external providers.
 

Part G: Accessibility in our Schools

Part H: Statement of Incidental Expenses

Part I: Evaluation of Program/Service

Part J: Research

The KPRDSB will consider opportunities to collaborate with external agencies to conduct research which benefits the pupils and employees of the KPRDSB as well as the community at large.
The Application for Permission to Conduct a Research Study must be made in writing and submitted to the Chairperson of the Research Advisory Committee.
For further information, see: https://www.kprschools.ca/our-board/contact-us/requests-to-conduct-research/

Part K: Police Records Check

It is understood that
 

Part L: Proof of Insurance

It is understood that:
 

Part M: Worker Safety and Insurance

It is understood that:
 

Part N: Application Submission Information

Please print & sign form and submit to address below (right-click on document and select print):

I certify that the information provided above is accurate and true to the best of my knowledge.

____________________________                        __________________________

     Signature                                                           Position    


Chair of the Supplemental Student Services Committee
Kawartha Pine Ridge District School Board
1994 Fisher Drive, PO Box 7190
Peterborough, Ontario
K9J 7A1

 
For Information Contact:
Secretary - Attendance and Counselling,
Psychological Services and Speech-Language
Extension 2176
Telephone: (705) 742-9773
Toll Free: 1-877-741-4577
Fax: (705) 760-8665
Website: www.kprschools.ca

Part O: FOR OFFICE USE ONLY

Date received: __________________________________


KPRDSB Supplemental Student Services Committee review date: ___________________________


Application Review: 


◊   Program is consistent with KPRDSB's stated mission, vision, and values.


◊   Supplements, and does not duplicate, services by Professional School Board staff.


◊   Requests for space/materials does not compromise KPRDSB staff to execute duties.


◊   Supervisory relationships are satisfactory.


◊   Adherence to KPRDSB standards of consent, confidentiality, equity, and human rights.


◊   Consent form and information letters meet Board standards.


◊   Measurement/evaluation tools meet Board standards.

 
Application: ◊   Approved           ◊   Declined

Reason for denial: ______________________________________________________



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