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

1) Participant information

2) Program information

A Support Worker has been retained to work exclusively with the participant in the following programs.

3) Support worker information

4) Support worker responsibilities

I understand that the Support Worker will be responsible for the following:

1. Keeping participant within program boundaries
2. Ensuring participant participation in programming to the best of their ability
3. Ensuring participant follows program etiquette
4. Supporting and adhering to the accommodation plan for the program and participant
5. Adhering to program policies and procedures related to confidentiality, suspicion of abuse/neglect, and dispensing of medication
6. The Support Worker will not supervise other participants or the program itself. When a situation requires attention, Support Worker will discuss it with Program Staff
7. In the event of an emergency, Support Worker will follow the instructions of the Program staff

5) Responsibilities

• I agree to advise 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 the Support Worker complies with the above stated duties and will respond in a timely manner to any concerns expressed by Program Staff with respect to the Support Worker
• I understand that in the event the Support Worker fails to fulfill their duties and responsibilities, as noted and agreed to above, the participant may be refused ongoing participation in the program at the sole and absolute discretion of the Program Coordinator.

6) Support worker not an employee

I understand and agree that the Support Worker is not an employee of The Corporation of the City of Kitchener/City of Waterloo. I understand and agree that the 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 the 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 the Support Worker, or by an act, omission or negligence of myself in retaining and supplying the Support Worker to the Program herein.

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

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