This form is to be completed by a Third Party Service Provider as application for consideration of the provision of a Personal Support Worker in-classroom student support 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 - 3.8.4 and in accordance with PPM 149.
Part A: Third Party Information
Part B: Nature of Request
Part C: Service Description
Part D: Staff Qualifications and Responsibilities (Complete if external to KPRDSB)
Part E: Supervision Schedule (Complete if external to KPRDSB)
Part F: Accessibility in our Schools
Part G: Statement of Finances
Third Party Service Providers requesting consideration for funding a Personal Support Worker through KPRDSB shall be responsible only for reimbursing the Board for the actual expenses incurred including salary and salary-related costs and related expenditures, including transportation and special services. The amount will be communicated to the Third Party Service Provider prior to the completion of the Collaboration Agreement.
Part H: Evaluation of Service
Part I: Police Records Check
Part J: Proof of Insurance
Part K: Proof of Certificate of Clearance
Part L: 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 M: 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.
◊ External Personal Support Worker Service does not duplicate services by KPRDSB staff.
◊ Requests is for funding of a KPRDSB staff.
◊ Supervisory relationships are satisfactory.
◊ Adherence to KPRDSB standards of consent, confidentiality, equity, and human rights.
◊ Measurement/evaluation tools meet Board standards.
Application: ◊ Approved ◊ Declined
Reason for Denial: ______________________________________________________
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