HR-16-101 Terms and Conditions Form for Unpaid Post-Secondary Placements
B2. CONDITIONS OF THE UNPAID PLACEMENT (to be defined by the placement Administrator/Supervisor)
Please describe the major responsibilities and any specific terms or conditions of the work/academic placement:
A valid Police Vulnerable Sector Check is required for all placements within the WRDSB (dated within the past 6
months) and must be provided to the placement supervisor the first day of placement. *May take up to 3 weeks to obtain.
SECTION C: Acknowledgement and Signatures
C1. PLACEMENT COORDINATOR SIGNATURE (select and acknowledge one of the following)
I confirm that the placement is a requirement of an academic program and that the institution/training agency
coordinating the student placement is:
Part of an Ontario publicly-supported post-secondary education or training program that is funded
through the Ministry of Training, Colleges and Universities (MTCU) operating grant; or
Is not part of an Ontario publicly-supported post-secondary education or training program funded
through the MTCU operating grant. Proof of Workplace Safety Insurance Board (WSIB) coverage or valid
insurance is attached.
Placement Coordinator’s Signature
C2. STUDENT SIGNATURE (select and acknowledge both of the following)
I acknowledge and accept the conditions of the unpaid placement.
I acknowledge that if I am injured or contract a disease while performing work duties at the unpaid
placement, the Waterloo Region District School Board and/or training agency/institution will disclose
personal information to the Ministry of Training, Colleges and Universities and/or Workplace Safety
Insurance Board, if relevant to a workplace insurance compensation claim.
PLEASE ENSURE THAT THE ORIGINAL COMPLETED FORM IS PROVIDED TO THE ADMINISTRATOR/SUPERVISOR
OF THE WRDSB PLACEMENT SITE PRIOR TO THE START OF THE PLACEMENT.
A completed copy of this form, along with all other unpaid placement documentation,
must be retained on site by the administrator/supervisor or office of the WRDSB
supervising the placement, for a minimum of the duration of the placement plus six
Notice of Collection: Personal information contained on this form is collected under the authority of the current Education Act of the Province of Ontario, and in accordance with the Municipal Freedom
of Information and Protection of Privacy Act. It will be securely stored in your employee file and used for administrative purposes. Questions about your employee file should be directed to the Human
Resource Services Department. Questions about this notice of collection should be directed to the Freedom of Information, Privacy and Records Information Management Officer, Waterloo Region
District School Board, Education Centre, 51 Ardelt Avenue, Kitchener, ON N2C 2R5 or email@example.com
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