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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

Name of agency:

Mailing address:

Web address:

Phone number and Fax number

Agency provides service in:

Peterborough County

Municipality of Clarington

Northumberland County

Executive Director/Owner:

Lead contact name, email and phone number:

Validation of agency status

A copy of accreditation or licence attached

Part B: Program / Service Description

Program title:

Goals and objectives:

Target group:

Program description:

Languages the program/service is delivered in:

English

French

Other

Please list other languages program is delivered in, if applicable.

Expected outcomes:

Program timelines: (How many sessions, how frequently, timelines)

Please read the Board Mission, Vision and Values: https://www.kprschools.ca/our-board/about-us/mission-vision-values/

Evidence of congruence with Board Mission, Vision and Values:

Part C: Staff Qualifications and Responsibilities

Please list relevant agency staff, and their qualifications.

Roles and responsibilities of the stated staff in program/service delivery:

Part D: Supervision Schedule

Please list the name(s) of their supervisor(s):

Supervision schedule (frequency, amount of time):

Part E: Informed Consent

Procedures for obtaining informed consent:

In cases where a student is withdrawn from regular classroom services, please outline procedures for obtaining informed consent from adult learners, and from parents of student under 18 years of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.
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

(1) Copy of consent form is attached.

(2) Copy of information letter is attached.

Part F: Space Resources and Materials

Please provide a description of the school Board resources (including space and materials) required in the delivery of the proposed program or service.

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.

Yes, I agree

Part G: Accessibility in our Schools

Please provide a description of any accessibility needs the External Agency staff may have. For example, accommodations required for assistive devices, service animals, personal support persons, etc.

Part H: Statement of Incidental Expenses

Please itemize any anticipated costs associated with the proposed program/service.

Part I: Evaluation of Program/Service

The KPRDSB and external agency staff must collaborate on the evaluation of programs and services provided as a component of the yearly review. Please describe the proposed method of evaluation. **Attach any relevant measurement tools.

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

when a Collaboration Agreement is signed external agency staff who are working in schools/or directly with students, will be required to obtain and submit to the Board a current police records check (including a vulnerable sector screening, and a pardoned sexual offender database search) prior to providing any services or programs in schools. Any expenses incurred will be the responsibility of the external agency.

under the terms of the Collaboration Agreement, KPRDSB has sole and unfettered discretion to prohibit external agency staff members from entering the schools and to terminate the Collaboration Agreement if the external agency fails to obtain or renew criminal reference checks according to KPRDSB Policy.

Part L: Proof of Insurance

It is understood that:

once a Collaboration Agreement is signed, the External Agency is required to provide proof that their staff is covered by insurance while working on KPRDSB property. External agencies must carry their own insurance (minimum $2,000,000) to insure against civil litigations alleging incompetence, professional errors, omissions or charges laid by parents/legal guardians. Such a policy shall contain a cross liability clause, an endorsement certifying that KPRDSB is included as an additionally named insured, and that the policy will be valid for the entire period of the collaboration agreement. Evidence of insurance coverage must be submitted to the KPRDSB prior to the commencement of any programs or services in schools.

Part M: Worker Safety and Insurance

It is understood that:

once a Collaboration Agreement is signed, the External Agency will provide a Certificate of Clearance from the Workplace Safety and Insurance Board indicating the agency is in good standing. The Agency will be required to provide a Certificate of Clearance every 60 days, where applicable.

Part N: Application Submission Information

Submission date:

Name of external agency staff who completed the application.

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: ______________________________________________________