Form

Suburbs

Parent/Guardian Support Worker Agreement for Programs of The Corporation of the City of Kitchener/City of Waterloo

 

1) Participant Information

2) Program Information


3) Support Worker Information

4) Support Worker Responsibilities

I understand that my child’s Support Worker will be responsible for the following:

  1. Will keep my child within the Program boundaries.
  2. With appropriate accommodation, will ensure the participation of my child in a minimum of 50% of the Program activities.
  3. Will participate fully in the scheduled Program activities (Note: where my child is withdrawn from an activity, the Program leaders must be notified).
  4. Will encourage my child to follow the 5 general rules of behaviour;
    • Keep your hands and feet to yourself
    • Speak nicely/positively to each other
    • Touch only what belongs to you
    • Stay within the activity area
    • Listen to the leaders/instructors
  5. Will support and adhere to the behaviour management plan for the Program.
  6. Will be familiar with and adhere to Program policies related to confidentiality, suspicion of child abuse/neglect, and dispensing of medication.
  7. Will provide input to the leaders. My child’s Support Worker will not supervise the other children or the Program itself but where my child’s Support Worker observes a situation which requires attention the Support Worker will discuss it with the Program leaders.
  8. In the event of an emergency will follow the instructions of the Program leaders.

5) Parent(s)/Guardian(s) Responsibilities

I agree to advise my child’s Support Worker of their responsibilities as set out above.
I agree to provide a Support Worker who is 15 years of age or older.
I will ensure that my Support Worker complies with the above stated duties and will respond in a timely manner to any concerns expressed by Program leaders with respect to my Support Worker.
I understand that in the event that my child’s Support worker fails to fulfill their responsibilities as noted and agreed to above, my child may be refused ongoing participation in the Program at the sole and absolute discretion of the Program leaders.

6) Support Worker Not an Employee

I understand and agree that my child’s Support Worker is not an employee of The Corporation of the City of Kitchener/City of Waterloo. I understand and agree that my child’s Support Worker is not an employee of any Neighbourhood Association affiliated with the Corporation of the City of Kitchener/City of Waterloo. I understand and agree that my child’s Support Worker is not covered by the insurance or the WSIB program supplied by the Corporation of the City of Kitchener/City of Waterloo.

7) Indemnification and Release of Liability

I agree to indemnify and hold harmless the Corporation of the City of Kitchener/City of Waterloo and its Mayor, Councillors, officers, employees, agents and volunteers, and the affiliated Neighbourhood Association of the Corporation of the City of Kitchener/City of Waterloo at which the Program is held and its officers, employees, agents and volunteers, from any and all claims, demands, actions, losses, causes of action, proceedings, suits, damages, expenses or liability of any kind, including reasonable legal fees and expenses of litigation, brought by any person, whether in respect of death, damage, harm or injury to person or damage to property, arising from any occurrence occasioned, whether in whole or in part, whether directly or indirectly, by an act, omission or negligence of my child’s Support Worker, or by an act, omission or negligence of myself in retaining and supplying my child’s Support Worker to the Program herein.

I hereby acknowledge that I have read the foregoing carefully and understand and agree to its contents.

Clear

Personal information is being collected under the authority of s.28 (2) of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) and will be used to administer the relevant programs and services. This information will be shared with only staff who require it for their work as part of providing Neighbourhood Programs and Services. Please note that your personal information will be stored in a Third Party server located in Waterloo, Ontario. The personal information collected herein will be used ony for the purposes relating to the program and will be protected in accordance to the requirements stipulated in the MFIPPA.

Inquiries about the collection, use of disclosure of your personal information should be directed to Loriann Palubeski, Manager, Programs and Resource Services, 519-741-2200 ext 7623, loriann.palubeski@kitchener.ca



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