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
Part B: Program / Service Description
Please read the Board Mission, Vision and Values: https://www.kprschools.ca/our-board/about-us/mission-vision-values/
Part C: Staff Qualifications and Responsibilities
Part D: Supervision Schedule
Part E: Informed Consent
Part F: Space Resources and Materials
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
Part L: Proof of Insurance
Part M: Worker Safety and Insurance
Part N: Application Submission Information
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 CommitteeKawartha Pine Ridge District School Board1994 Fisher Drive, PO Box 7190Peterborough, OntarioK9J 7A1
For Information Contact:Secretary - Attendance and Counselling,Psychological Services and Speech-LanguageExtension 2176Telephone: (705) 742-9773Toll Free: 1-877-741-4577Fax: (705) 760-8665Website: 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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