Child Care and Learning Centre
Volunteer File Package
Welcome to volunteering at the University of Guelph’s Child Care and Learning Centre. We are excited
to have you join our Centre and look forward to working with you. Prior to starting your volunteer
placement please ensure that you have the following information ready for your file.
File Contents
Collected
Completed Staff/Student/Volunteer Health History Form
Completed Pre-Employment Immunization Form for Childcare Staff
Ensure that you have the following immunizations complete:
One adult dose of Tdap and a dose of Td current within the last 10
years
Two doses of MMR, except if born before 1970
Copy of your Immunization Records
Vulnerable Sector Police Check
A VSPC can be obtained from your local police station and must be less than 5
years old. We will take a true copy of the original to keep in your file.
Completed Notice with Respect to the Collection of Personal Information
Completed Worker Health & Safety Awareness Training Certificate
Can be completed through the following link:
https://www.labour.gov.on.ca/english/hs/elearn/worker/index.php
Completed Release of Liability, Waiver of Claims, Assumption of
Risks and Indemnity
You will also need to complete a current Policy Review, including signing off on all current
Individual Anaphylaxis Plans prior to starting your volunteer placement.
STAFF/STUDENT/VOLUNTEER HEALTH HISTORY FORM
The Child Care and Early Years Act (2014), Staff Qualifications - Health assessments and immunization of staff; Section 57 states that:
57. (1) Every licensee of a child care centre shall ensure that, before commencing employment, each person employed in each child
care centre it operates has a health assessment and immunization as recommended by the local medical officer of health. (2) Every
licensee of a home child care agency shall ensure that, before any child is provided with home child care, each home child care
provider at a premises at which the licensee oversees the provision of home child care and each person who is ordinarily a resident of
the premises or regularly at the premises has a health assessment and immunization as recommended by the local medical officer of
health. (3) Subsections (1) and (2) do not apply where the person, or where the person is a child, a parent of the person, objects in
writing to the immunization on the ground that the immunization conflicts with the sincerely held convictions of the person or parent
based on the person’s or parent’s religion or conscience or a legally qualified medical practitioner gives medical reasons in writing to
the licensee as to why the person should not be immunized.
Name: Email address:
Permanent Address: City:
Postal Code: Phone:
Campus Address: City:
Postal Code: Phone:
Physician's Name: Phone:
Date of Last Health Assessment:
In case of an emergency, please contact:
Name: Relationship:
Address: Phone:
A. Do you have any health conditions which could require special attention? Yes
No
If yes, please explain:
B. Allergies: (medication, food, environmental etc.):
C. To the best of my knowledge, I am in good general health and fully able as a staff member, student or
volunteer to participate in the Child Care agency named above.
Signature Date
click to sign
signature
click to edit
Pre-Employment Immunization Form
for Childcare Staff
All information on this form is collected and retained by employer. Please attach a copy of your immunization record.
Name: Date of
Birth:
Childcare: Date of
Hire:
Required
Immunizations
1) Tetanus, Diphtheria, Pertussis (Tdap) - one adult dose followed by Tetanus, Diphtheria (Td) every 10 years
Date (Tdap): Date (Td):
2)
Measles,
Mumps, and Rubella
(MMR) -
two doses required
if
born in 1970 or later. Adults born before 1970 can be
considered immune.
Date: Date:
OR
Laboratory evidence of immunity to
Measles,
Mumps, and
Rubella (bloodwork)
Laboratory evidence of immunity attached
Recommended
Immunizations
1) Varicella (chickenpox) – two doses OR laboratory evidence of immunity (bloodwork)
Date: Date:
Laboratory evidence of immunity attached
2) Hepatitis B – two* or three dose series OR laboratory evidence of immunity (bloodwork)
Date: Date: Date:
Laboratory evidence of immunity attached
3) Hepatitis A - two or three** dose series
Date: Date: Date:
4) Pneumococcal Conjugate – one dose if over 50 years of age
Date:
5) Influenza (flu shot) - annually
Additional Recommendations for Women of Childbearing Age
Laboratory evidence of immunity to:
Cytomegalovirus (CMV)
Rubella (German measles)
Exemption
from
Immunization:
attach
written statement of exemption
Medical Exemption Date:
Statement of Conscience or Religious Belief Date:
Staff Signature: Date:
*Please note childcare staff may have received a two (2) dose series of Hepatitis B vaccine as part of a voluntary immunization
program in school in Ontario.
** Three dose series if given as a combined hepatitis A/B vaccine.
Form supplied by Wellington-Dufferin-Guelph Public Health (03/2015)
click to sign
signature
click to edit
Notice with Respect to the Collection of Personal Information
(Freedom of Information and Protection of Privacy Act)
Each staff, student and volunteer in a licensed child care centre or person
employed by / associated with a licensed home child care agency must complete
this form.
In administering and enforcing the Child Care and Early Years Act, 2014 (CCEYA),
Ministry of Education inspectors, program advisors and the director under the CCEYA
may collect and review personal information about staff employed by a licensed child
care centre or employed by or associated with a licensed home child care agency under
the authority of s. 30, 31, 67(1) and 69(1) of the CCEYA and s. 53, 54, 55, 56 and 57 of
O. Reg. 137/15 under the CCEYA to ensure that the licensed child care centre or home
child care agency is complying with the CCEYA and O. Reg. 137/15.
This form is required to be kept for the ministry’s review at the child care centre where
you are employed or the head office of the home child care agency.
Your personal information may be provided by your employer in connection with an
application for approval of a Supervisor, a person to take the place of a Registered
Early Childhood Educator or approval of a Home Child Care Visitor, if applicable.
Information collected in the licensing process about Registered Early Childhood
Educators may be shared with the College of Early Childhood Educators if necessary
for the enforcement of the Early Childhood Educators Act, 2007.
Questions concerning the direct or indirect collection of personal information may be
addressed to the:
Child Care Quality Assurance and Licensing Branch
Early Learning Division
Ministry of Education
900 Bay Street, 24th floor, Mowat Block
Toronto, ON M7A 1L2
416-314-8373
Name (print) ______________________________________________
Signature ______________________________________________
Date ______________________________________________
A copy of the form should be given to the person who completes it.
CHILD CARE AND LEARNING CENTRE
Volunteers: by signing this document you will waive certain legal rights, including the right to sue
Please Read Carefully!
RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY:
In consideration of approval to enter a work experience program in the University of Guelph Child Care
and Learning Centre, I hereby agree as follows:
TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the University of
Guelph and its directors, officers, employees, and representatives (all of whom are hereinafter
collectively referred to as “the Releasees”) To release the releasees from any and all liability for
any loss, damage, injury or expense that I may suffer, or that my next of kin my suffer as a result
of my participation in this work experience program, due to any cause whatsoever, including
negligence, breach of contract or breach of any statutory or other duty of care.
IT IS MY RESPONSIBILITY to ensure that I have adequate medical, personal health, dental and accident
insurance coverage, as well as protection of my personal possessions;
TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to
property of, or personal injury to, any third party, resulting from my participation in this work experience
program, if such liability is as a result of my acting outside the scope of my duties and responsibilities.
THIS AGREEMENT SHALL be effective and binding upon my heirs, next of kin, executors, administrators,
assignees and representatives in the event of my death or incapacity;
IN ENTERING INTO THE AGREEMENT, I am not relying upon any oral or written representations or
statements made by the Releasees other than what is set forth in this Agreement.
I FREELY ACCEPT AND FULLY ASSUME all risk, dangers and hazards and the possibility of personal injury,
death, property damage or loss, resulting from my participation in this program
I have read and understand this agreement and I am aware that by signing, I am waiving certain legal
rights which I or my Heirs, Next of Kin, Executors, Administrators and Assignees may have against their
Releasees.
Name Address
Telephone Signature
Signature of Parent or Legal Guardian Relationship to Minor
Director, Chair or Witness Signature Date
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome