Support Provider Form – SelfDesign Forms

Welcome to SelfDesign® Learning Foundation!

SelfDesign® Learning Foundation is a registered Canadian charity, incorporated as a not-for-profit organization in the province of British Columbia (“SelfDesign”), operating as a B.C. independent provincial online learning school (POLS). For more information about SelfDesign programs, please visit www.selfdesign.org.

As a school making payments to you on behalf of our learners, we require the following before you begin to provide support to our learner.

Please send all questions regarding this form to sdsupportprovider@selfdesign.org.

Contact Information

Vendor Name *

Name used for communication. This may be the same as your legal name.

Legal Name for Payment *

Please enter the legal company name or legal business name (if sole proprietor, etc.)

Contact Name *

Full Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Email *

Confirm Email

Phone Number *

GST Number

Required if charging GST

Business Website / URL

Select 1 of the 3 options below: *

SEA: Support Education Assistant - you are an individual SEA who will be working directly with the learner / parent to achieve IEP goals under the direction of the SelfDesign Learning Consultant.
PSP: Professional Support Provider - you are an individual or an organization who will be working directly with the learner / parent privately or in group sessions, and have training, certification and/or licensing to provide a specific service.
I am submitting this form on behalf of a Facility or Rec Centre run by Municipality, Regional District or other local BC government.

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Support Education Assistant (SEA)

A SEA is an Individual who works with a learner to achieve IEP goals under the direction of the SelfDesign Learning Consultant *

I confirm that I am 19 years of age or older.

Document 1

A scan of your current professional certification or registration*

If you do not have professional certification/registration, please provide a copy of your resume (or statement of experience).

Resume or Certification *

Certification submitted (ie. BC Teacher)
Resume or Statement of Experience submitted
I have emailed sdsupportprovider@selfdesign.org for help with this

Upload File

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Document 2

A completed Solicitor General’s Criminal Record Check (CRC) for working with children and vulnerable adults category: *

Before you begin working with a learner, we require a copy of your current, valid BC Solicitor General Criminal Record Check (CRC) on file. This CRC must be issued by the Criminal Records Review Program (CRRP) at the BC Ministry of Justice and specifically cover working with children and vulnerable adults.
If another individual will be working with a SelfDesign learner, you must notify us. That individual is also required to obtain a CRC through the CRRP before beginning work with the learner.
Please note: SelfDesign cannot accept local RCMP Criminal Record checks or checks from third-party websites (e.g., mybackcheck.com). Only CRCs obtained through the CRRP using the process provided by SelfDesign are valid.
We will accept a copy of your certification in lieu of the CRC if you are part of the "Regulated Professions" list in the Ministry website: Click here to see the list.

Instructions for Completing a CRC for SelfDesign (PDF)

Criminal Record Check *

I am in the process of applying for a CRC or sharing a current one through the BC Ministry by using the instructions included within this form. (Note: A reminder to complete this step will be sent to you in 2–3 business days.)
I have attached my certificate for a regulated profession in the Document 1 section
I have emailed crimcheck@selfdesign.org for assistance

Document 3

Confirmation of WorkSafeBC Coverage

SelfDesign requires that all SEA contractors have WorkSafeBC (WSBC) coverage. Support Education Assistants without WorkSafeBC coverage will be considered to be SelfDesign workers for the purposes of certain requirements of WorkSafe BC and will need to complete SelfDesign's Occupational Health & Safety package, which includes Anti-Bullying and Harassment, Occupational Safety and Lone Worker Monitoring.

WorkSafe BC Coverage *

I need WorkSafeBC through SelfDesign and will comply with coverage as above.
I have my own WorkSafe coverage and have an WSBC number. I confirm that I am in good standing with WorkSafeBC.

WorkSafeBC Number *

Document 4

Transportation Documents:

Valid current Driver’s License
Proof of 3rd party Liability Insurance (Please note that $5,000,000 Third Party Liability Automobile insurance is required on any vehicle transporting a SelfDesign learner).

Will you be transporting a SelfDesign Learner? *

I will not be transporting a SelfDesign Learner
I will be transporting a SelfDesign Learner.

Upload Files

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

If you will be transporting a SelfDesign Learner, please submit a copy of your current Auto Insurance (as above) and Driver’s License. In addition, if your Auto insurance or Driver's license expires at any time during your support of the SelfDesign Learner, you will be responsible to submit the renewed copy or suspend transportation until SelfDesign receives a current copy.

Document 5

Your signed Support Education Assistant Agreement specific to each learner.

You will be sent a contract agreement / budget information for each learner requested by Learning Consultants after submission and approval of all required documents.

SEA/SP Policies *

I have reviewed the SelfDesign SEA/SP policies in the following link: https://policies.selfdesign.org/sea-policies/

Declaration *

I hereby confirm that I am submitting this form and the required documents to SelfDesign, knowing that SelfDesign will be relying on the truth of their contents. I represent and warrant to SelfDesign that the documents I am submitting to SelfDesign are true copies of the original documents and that the information contained in the documents is true and correct in every respect.

Signature *

Clear Signature

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Professional Support Provider

A professional support provider is an individual or organization who:

has training, certification and/or licensing to provide a specific service (ie: SLP, OT, Physio, Specialized tutors, Consulting)
facilitates group or individual classes or sessions through an organization (ie: Learning Centre, Rec Centre, Music Studios, Cub Scouts)
teaches groups or individuals specific skills (ie: Music, Art, Physical Activities, Equine)

Type of Support Provided *

Art classes
Art therapy
Music lessons
Music therapy
Performing Arts, Theatre
Behavioural Intervention
Counselling and/or Consulting
Psychological Assessments
Equine Experience
Movement-related (sports, physical education)
Occupational Therapy
Speech and Hearing Therapy
Other Professional Therapy
Specialized Academic Support and/or Tutoring

Check all that apply

Description

Please describe the type of support provided

I am *

an individual contractor
an organization or business

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I confirm *

I confirm that I am 19 years of age or older.

Document 1

A copy of your current professional certification or license. *

If you do not have a professional certification/license, please provide a copy of your Resume (or statement of experience and/or website bio).

Resume or Certification *

Current professional registration or certification submitted
Resume or Statement of Experience submitted
I have emailed sdsupportprovider@selfdesign.org for help with this.

Upload File

Drag & Drop Files, Choose Files to Upload

Document 2

A completed Solicitor General’s Criminal Record Check (CRC) for working with children and vulnerable adults category: *

Before you begin working with a learner, we require a copy of your current, valid BC Solicitor General Criminal Record Check (CRC) on file. This CRC must be issued by the Criminal Records Review Program (CRRP) at the BC Ministry of Justice and specifically cover working with children and vulnerable adults.
If another individual will be working with a SelfDesign learner, you must notify us. That individual is also required to obtain a CRC through the CRRP before beginning work with the learner.
Please note: SelfDesign cannot accept local RCMP Criminal Record checks or checks from third-party websites (e.g., mybackcheck.com). Only CRCs obtained through the CRRP using the process provided by SelfDesign are valid.
We will accept a copy of your certification in lieu of the CRC if you are part of the "Regulated Professions" list in the Ministry website: Click here to see the list.

Instructions for Completing a CRC for SelfDesign (PDF)

Criminal Record Check *

I am in the process of applying for a CRC or sharing a current one through the BC Ministry by using the instructions included within this form. (Note: A reminder to complete this step will be sent to you in 2–3 business days.)
I have attached my certificate for a regulated profession in the Document 1 section
I have emailed crimcheck@selfdesign.org for assistance

Document 3

Transportation Documents:

Valid current Driver’s License
Proof of 3rd party Liability Insurance (Please note that $5,000,000 Third Party Liability Automobile insurance is required on any vehicle transporting a SelfDesign learner).

Will you be transporting a SelfDesign Learner? *

I will not be transporting a SelfDesign Learner
I will be transporting a SelfDesign Learner.

Upload File

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Declarations

Professional Liability Insurance *

I represent and warrant to SelfDesign that I have and will maintain in force insurance with respect to the services I will be providing to the Learner, and that such insurance is against such risks and to such limits as are in accordance with prudent business practice given the nature of the services I provide. I agree to provide SelfDesign with evidence of such insurance upon request.

Professional Status and Documentation *

I hereby represent and warrant to SelfDesign that I am a member in good standing of my professional organization (if applicable), that the documents I am submitting to SelfDesign are true copies of the original documents, and that the information contained in the documents is true and correct in every respect.

Professional Documentation *

I am responsible to submit a renewed copy of any submitted documents (CRC, professional registration, driver’s license, or automobile liability insurance) prior to the expiration date in order to avoid interruption of the SelfDesign learner’s support. All required documents on file with SelfDesign will be a current and valid copy of the original.

Declaration re: Submission *

I hereby confirm that I am submitting this form and the required documents to SelfDesign, knowing that SelfDesign will be relying on the truth of their contents.

Signature *

Clear Signature

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Required Documentation

Certification *

All individuals have current training, professional registration or certification valid for the support which they are providing to SelfDesign Learners and, if applicable, are in good standing with their respective professional organizations.

Criminal Record Check (CRC) *

All individuals working with SelfDesign Learners have a current BC Solicitor General CRC for working with children and vulnerable adults.

Liability Insurance *

Our organization has and will maintain in force insurance with respect to the services we will be providing to SelfDesign Learners, and such insurance is against such risks and to such limits as are in accordance with prudent business practice given the nature of the services we provide. We agree to provide SelfDesign with evidence of our insurance upon request.

Transportation *

Members of our organization will not be transporting a SelfDesign Learner
Members of our organization will be transporting a SelfDesign Learner

Please confirm whether any members of your organization will be transporting a SelfDesign Learner by marking the appropriate checkbox above

Transportation Confirmation *

our organization carries $5,000,000 Third Party Liability Automobile insurance on vehicle(s) transporting a SelfDesign Learner

Transportation Confirmation 2 *

our organization ensures valid and current Driver’s Licenses for each individual driver transporting a SelfDesign Learner

Declaration re: Submission *

I hereby confirm that I have the authority to submit this form on behalf of the Organization above, knowing that SelfDesign will be relying on the truth of the contents. I hereby represent and warrant to SelfDesign on behalf of our organization that the above statements are true and correct to the best of my knowledge, having made due inquiry. In the event that SelfDesign requests support documentation, I hereby represent and warrant that the documents I submit are true copies of the original documents, and that to the best of my knowledge, the information contained in the documents is true and correct in every respect.

Signature *

Clear Signature

Name of Signer *

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Required Documentation

Certification *

All individuals have current training, professional registration or certification valid for the support which they are providing to SelfDesign Learners and, if applicable, are in good standing with their respective professional organizations.

Criminal Record Check (CRC) *

All individuals working with SelfDesign Learner(s) have a current CRC for working with children and vulnerable adults.

Liability Insurance *

Our organization has and will maintain in force insurance with respect to the services we will be providing to SelfDesign Learners, and such insurance is against such risks and to such limits as are in accordance with prudent business practice given the nature of the services we provide. We agree to provide SelfDesign with evidence of our insurance upon request.

Declaration re: Submission *

I confirm that I am submitting this form to SelfDesign, knowing that SelfDesign will be relying on the truth of their contents. I hereby represent and warrant to SelfDesign on behalf of our organization that the above statements are true and correct to the best of our knowledge, having made due inquiry.

Contact Person Name *

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Thank you. If you are ready to complete your form, please click "Submit". If you need more time, please select "Save and Continue Later".

Support Provider Listing

SelfDesign maintains a Support Provider List that SelfDesign’s Learning Consultants and families can reference.

Yes, I would like to be included as available to take new Learners.
No, do not include my contact details as I am not available to take new Learners.

Select all that apply

Vancouver Coast & Mountains
Vancouver Island & Coast
Thompson Okanagan
Northern BC
Cariboo Chilcotin Coast
Kootenay Rockies
Online / Outside of BC

Name of City or Area (can be multiple)

About Yourself

Please provide a paragraph description of yourself and the support you will be providing to our Learner(s). This information will be viewed by Learning Consultants who are looking for new supports for their learners. This paragraph is about you - not a specific learner that you may be working with. Thank you!

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