Support Provider Form – SelfDesign Forms

Welcome to SelfDesign® Learning Foundation!

SelfDesign® is an independent Provincial Online Learning School (POLS). To learn more about our programs, visit www.selfdesign.org.

This form is the first step to becoming a SelfDesign Support Provider. We use this form to:

Collect your contact information
Learn about the services you provide
Collect required documents

After you submit the form, we will review it and contact you if any additional information is needed.

If you have any questions please reach out to us at: sdsupportprovider@selfdesign.org.

Contact Information

Support Provider/Organization Name *

(Name of the person , organization, or operating name)

Legal Name for Payment *

(Legal name or Legal business name)

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: *

Support Education Assistant (SEA) is a works individually with a learner to achieve IEP goals under the direction of the learning consultant
Professional Support Provider (PSP) - 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)

This page collects what we need to set you up as a Support Education Assistant (SEA). You will:

Confirm your age
Upload proof of your qualifications or experience
Complete or share a Solicitor General’s Criminal Record Check
Confirm your WorkSafeBC coverage
Confirm if you will be transporting a learner.

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.

Qualifications

Please upload either your certification, resume, or statement of experience.

Resume or Certification *

Certification uploaded (e.g. BC Teacher)
Resume or statement of experience uploaded
SelfDesign already has my certification, resume, or statement of experience on file
I need assistance. I will email sdsupportprovider@selfdesign.org

Upload File

Drag & Drop Files, Choose Files to Upload

Criminal Record Check (CRC)

SelfDesign receives funding from the BC Ministry of Education and Child Care. Because of this, all contractors and support providers who work with children or vulnerable adults must complete a Criminal Record Check (CRC).

The CRC must be completed through the BC Criminal Records Review Program (CRRP). Police or RCMP criminal record checks are not accepted. CRRP clearances are valid for five years.

Getting started:

Please read the Criminal Record Check (CRC) FAQ
Watch the 3-minute video on the CRC application Process
You will need to pay the $28.00 fee
Use your BC Services Card login if you live in BC
Email crimcheck@selfdesign.org if you live outside of BC.

Next Step:

Review this CRC Instruction Link to get started.

Criminal Record Check *

I will apply for a CRC or share my current CRRP clearance by following the CRC Instructions provided.
I have uploaded my professional certification in the Qualifications section above as proof of my regulated profession (e.g., BC teacher, OT, or SLP).
SelfDesign already has my current Criminal Record Check (CRC) on file.
I need assistance and will email crimcheck@selfdesign.org

WorkSafeBC Coverage

SelfDesign requires all Support Education Assistants (SEAs) to have valid WorkSafeBC coverage.

All SEAs are also required to complete the Occupational Health and Safety (OHS) Orientation.

If you do not have your own WorkSafeBC coverage, SelfDesign will provide coverage for you. Our WorkSafe team will contact you with next steps.

WorkSafe BC Coverage *

I need WorkSafeBC coverage through SelfDesign
I have my own WorkSafeBC coverage

WorkSafeBC Number

Transportation of Learners

This section confirms whether you will be transporting a SelfDesign learner.

If you will be driving a learner, you will need to upload copy of:

a valid driver’s license;
Proof of third-party vehicle liability insurance (minimum $2 million in coverage).

Note: we also will send a Parental Permission to the learners family to sign.

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.

Policies and Declaration

SEA/SP Policies *

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

Declaration *

I confirm that the information and documents submitted are true and accurate. I understand that SelfDesign will rely on this information. I also confirm that any copies I provide are true copies of the original documents

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)

Select the type of supports provided *

Art classes
Art therapy
Music lessons
Music therapy
Performing Arts, Theatre
Behavioural Intervention
Counselling and/or Consulting
Psychological Assessments
Equine Experience
Movement Related
Occupational Therapy
Speech-Language Pathology
Other Professional Therapy
Specialized Academic Support
Other

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.

Qualifications

Professional Certification or Experience

Please upload a copy of your professional certification or registration.

If you do not have certification or registration, please upload your resume or a statement of experience.

Resume or Certification *

Professional registration or certification uploaded
Resume or Statement of Experience uploaded
I need assistance. I will email sdsupportprovider@selfdesign.org.

Upload File

Drag & Drop Files, Choose Files to Upload

Criminal Record Check (CRC)

The CRC must be completed through the BC Criminal Records Review Program (CRRP). Police or RCMP criminal record checks are not accepted. CRRP clearances are valid for five years.

Getting started:

Please read the Criminal Record Check (CRC) FAQ
Watch the 3-minute video on the CRC application Process
You will need to pay the $28.00 fee
Use your BC Services Card login if you live in BC
Email crimcheck@selfdesign.org if you live outside of BC.

Next Step:

Review this CRC Instruction Link to get started.

Criminal Record Check *

I will apply for a CRC or share my current CRRP clearance by following the CRC Instructions provided.
I have uploaded my professional certification in the Qualifications section above as proof of my regulated profession (e.g., BC teacher, OT, or SLP).
SelfDesign already has my current Criminal Record Check (CRC) on file.
I need assistance and will email crimcheck@selfdesign.org

Transportation of Learners

Valid current Driver’s License
Proof of third-party vehicle liability insurance (minimum $2 million in coverage).

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.

Policies and Declaration

Professional Liability Insurance *

I confirm that I have and will maintain professional liability insurance, if required, for the services I provide to SelfDesign learners. I agree to provide proof of insurance upon request.

I confirm that I am a member in good standing with my professional organization, if applicable. I also confirm that the documents I submit to SelfDesign are true copies of the originals and that all information provided is accurate. *

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 for submitting updated copies of any required documents (e.g., CRC, professional registration, driver’s licence, or automobile liability insurance) before they expire to avoid interruption of learner support.

Declaration re: Submission *

I confirm that the information and documents I am submitting to SelfDesign are accurate and that SelfDesign will rely on the truth of this information.

Services must be provided in accordance with applicable professional practice regulations and guidelines established by the Province of British Columbia and SelfDesign Learning Foundation. *

I confirm that I have reviewed and agree to follow all applicable rules, policies, protocols, and professional practice guidelines, including:

SelfDesign Support Provider Policies
Compliance and Health & Safety Policies

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 $2,000,000 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

If you would like to support more SelfDesign learners, you can choose to be listed as “Available to take
learners” in our Support Provider (SP) List. This list is used by our educators.

Would you like your information added to the SP List?

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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Thank you for your interest in SelfDesign® Learning Community. The current contents of your entry are not yet available to SelfDesign - please re-enter the form via the link below and click “Submit” when you are ready for SelfDesign to receive your submission.

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