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TERMS AND CONDITIONS FORM FOR UNPAID POST-SECONDARY PLACEMENTS (Waterloo Region District School Board)

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TERMS AND CONDITIONS FORM FOR
UNPAID POST-SECONDARY PLACEMENTS
HR-16-101
To be completed by the Post- Secondary Institution/Training Agency with the placement student and returned to
the Waterloo Region District School Board (WRDSB) prior to the commencement of the unpaid work/academic
placement. An equivalent form used by the institution or training agency may be submitted in place of this form.
For more information and resources visit: www.wrdsb.ca/unpaid-post-secondary-placements
SECTION A: Contact Information
A1. STUDENT INFORMATION
Full Name:
Student ID:
Local Address:
Primary Phone:
Alternate Phone:
A2. STUDENT EMERGENCY CONTACT
Full Name:
Primary Phone:
Relation:
Alternate Phone:
A3. INSTITUTION/TRAINING AGENCY INFORMATION
Institution/Training Agency:
Program:
Course:
Type of Placement:
Coordinator’s Name:
Title:
Coordinator’s E-mail:
Phone:
Ext:
Emergency Contact:
Phone:
Ext:
SECTION B: Placement Details (to be agreed upon by the placement Administrator/Supervisor)
B1. PLACEMENT LOCATION INFORMATION
School/Building(s):
Department(s):
Classroom/Office/Workstation Location(s):
Start Date:
End Date:
Supervisor’s Name:
Title:
Supervisor’s E-mail
Phone:
Ext:
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 privacy@wrdsb.ca
March 2020
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
Date
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.
Student’s Signature
Date
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
years.
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 privacy@wrdsb.ca
March 2020
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TERMS AND CONDITIONS FORM FOR UNPAID POST-SECONDARY PLACEMENTS (Waterloo Region District School Board)

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Completed 21 February 2021

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