Private support worker agreement form

Register a Private Support Worker

Provide the City of Waterloo with information about a private support worker for a program participant.
Why we are asking for your information:

The personal information and personal health information we collect in this form helps us support safe participation in programs and arrange appropriate support for participants. This information is protected under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). It will only be shared with staff on an as-needed basis. Complete details can be found under 'Terms and Conditions' at the end of this form.
Participant and applicant information

Provide your information and details about the participant.
Your full name
Your first and last name
Your email address
example@example.com
Are you completing this application for yourself? (Are you the participant?)
Participant's full name
Participant's first and last name
What is your relationship to the participant?
For example, parent or guardian
Program information

Provide the details for the City of Waterloo program where the support worker will help the participant.
Program name
Program location

Other
Support start date

MonthDayYear
Support end date

MonthDayYear
Add additional dates?
2nd support start date

MonthDayYear
2nd support end date

MonthDayYear
Add additional dates?
3rd support start date

MonthDayYear
3rd support end date

MonthDayYear
Add additional dates?
4th support start date

MonthDayYear
4th support end date

MonthDayYear
Add additional dates?
5th support start date

MonthDayYear
5th support end date

MonthDayYear
Add additional dates?
6th support start date

MonthDayYear
6th support end date

MonthDayYear
Add additional dates?
7th support start date

MonthDayYear
7th support end date

MonthDayYear
Add additional dates?
8th support start date

MonthDayYear
8th support end date

MonthDayYear
Add additional dates?
9th support start date

MonthDayYear
9th support end date

MonthDayYear
Support worker information

Provide details about the support worker.
Do you know who the support worker will be?
Name of private support worker
Name of special needs agency connected to support worker, if applicable
Name of contact person for special needs agency, if applicable
The support worker is 15 years of age or older
Private support workers participating in City of Waterloo programming must 15 years of age or older.
Responsibilities and acknowledgements

Read the following responsibilities and confirm your understanding and agreement.
The support worker will be responsible for the following tasks while supporting the participant:
1. Keeping the participant within the program boundaries.
2. Ensuring the participant's participation in programming to the best of their ability.
3. Ensuring the participant follows program etiquette.
4. Supporting and adhering to the accommodation plan for the program and the participant.
5. Adhering to the program policies and procedures related to confidentiality, suspicion of abuse/neglect, and dispensing of medication.
6. Supervising only the participant and no other participants, or the program itself. If a situation requires attention, the support worker will discuss it with program staff.
7. Following the instructions of program staff in the event of an emergency.
Read each item below and check the box to show that you agree.
Legal Responsibility and Liability

Read the statements below about responsibility and liability and check the boxes to confirm your agreement.
Support worker’s role and employment status
Applicant's indemnification and release of liability

I agree to indemnify and hold harmless the City and its elected officials, officers, employees, agents and volunteers, and the affiliated Neighbourhood Association of the City 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.
Sign and submit

Enter your name and today’s date to confirm that you have read, understand, and agree to the contents of this application. This acts as your digital signature. When you are done, select the 'Submit' button to complete the form.
Full name (typed signature)
Today's date (use numbers only – MM DD YYYY)

MonthDayYear
Terms and Conditions

Personal information is being collected under the authority of s.28 (2) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56 (the “MFIPPA”) and will be used to administer the relevant programs and services. This information will be shared only with staff who require it for their work as part of providing Community Programming. 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 only for the purposes relating to the program and will be protected in accordance with the requirements stipulated in the MFIPPA.

Inquiries about the collection, use of disclosure of your personal information should be directed to Inclusion Services Coordinator, 519-886-1177 ext. 27249, inclusion@waterloo.ca.
Should be Empty:

Register a Private Support Worker

Participant and applicant information

Program information

Support worker information

Responsibilities and acknowledgements

The support worker will be responsible for the following tasks while supporting the participant:

Legal Responsibility and Liability

Sign and submit

Terms and Conditions