Support Provider Agreement and Release

SUPPORT PROVIDERS AGREEMENT and RELEASE

By signing this Agreement and Release I acknowledge and agree that:

Support Providers are not Halton Support Services employees. Halton Support Services has provided

a list of names of available Support Providers and I am responsible for my selection of a Support

Providers. Halton Support Services is not responsible for disagreements I may have with the Support

Provider. I will resolve my problems directly with the Support Provider. Halton Support Services is not

responsible for the actions or conduct of any Support Provider I hire.

The Support Provider provided an up-to-date Police Reference Check to Halton Support Services at the

time of their information session for the respiteservices.com Support Provider Database. It is my

responsibility to check references and to ensure there is a current Police Reference Check on the

Support Worker.

A Support Provider is not a trained therapist. Her/his name is being provided to me as a possible

Support Provider. A Support Provider may be removed from the Support Provider Database at any time, it

is the sole discretion of the Respite Coordinators.

The Support Provider has acknowledged in writing that:

·       1. She/he is an independent support provider and is not an employee, agent or representative of the Services or respiteservices.com;

·       2. Except where my employer consents, or when legally required, I will keep information about

my employer and her/his family or my contract with my employer confidential;

·       3. She/he is solely responsible for any private vehicle she/he uses to transport persons served

by the Support Worker; and

·       4. She/he is solely responsible for her/his own health or accident insurance, or payment of taxes,

or contribution to Employment Insurance or CPP or other benefits plan.

In consideration of my being given access to the names of Support Provider, I release Halton Support

Services and respiteservices.com (which terms in this Agreement and Release includes all parties

legally responsible for Halton Support Services and respiteservices.com and their employees, officers

and directors) from all actions, causes of action, proceedings, claims, demands, losses, damages and

liabilities of every nature and kind arising from my dealings with Halton Support Services,

respiteservices.com and any Support Provider. I agree to indemnify the Halton Support Services and

respiteservices.com from all claims made against them as a result of my conduct. I will make no claim

against any party that may claim contribution or indemnity from Halton Support Services and

respiteservices.com.

Date: ___________________________

________________________________

Signature of Parent or Guardian Signature of Witness

________________________________ ________________________________

Printed Name of Parent or Guardian Printed Name of Witness

Hosted by Halton Support Services

respiteservices.com respects your privacy. We protect your personal information and adhere to all legislative requirements. We do not rent, sell or

trade our mailing lists. The information you provide to us will be used to connect you to suitable workers, keep you informed about our activities and

other respite programs/services and to send update forms. If at any time you wish to stop receiving this information, simply contact us at

905 844 7864 or via e-mail at hssrespite@cwsds.ca

53 Bond Street, Oakville, ON L6K 1L8 Phone: 905 844 7864 Fax: 905 849 6980