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

Support Provider or Organization Name *

Personal Contact Name

(For organizations)

Email *

Confirm Email

Payments will be made to *

Full name of the person or entity who the payments should be made out to.

Full Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone Number *

Website / URL

(If you have one)

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. (for example: Speech or Hearing therapy, Occupational therapy, Other professional therapies, Consulting, Counselling, Music, Art, Physical Activities/Movement, Equine Experience, Specialized Academic programs (ie: tutoring, cooking, nature, driving lessons, etc).
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

Click or drag a file to this area to upload.

Document 2

A current, valid BC Solicitor General Criminal Record Check (CRC) for working with children and vulnerable adults category:

Prior to beginning to work with a learner we require a copy of your current, valid BC Solicitor General CRC (Criminal Record Check) on file with SelfDesign, specifically for working with children and vulnerable adults. These are issued either online or manually by the CRRP (Criminal Records Review Program) at the BC Ministry of Justice, and cost $28.00 to create a new one, or you can share a current, valid CRC clearance letter completed within the past 3 years for free.

Please forward a copy of your CRC processing receipt to crimcheck@selfdesign.org so that we know when the CRC is underway.

Please note: SelfDesign can only accept the Solicitor General CRC for working with children and vulnerable adults category as per the instructions below. We CANNOT accept the local RCMP checks or ones from websites such as “mybackcheck.com”. Please do not obtain local RCMP checks or CRCs from anywhere other than through the avenues provided by SelfDesign through the CRRP (Criminal Records Review Program).

Governing Bodies and Regulated Professions: Members of the listed governing bodies are required to undergo a CRRP criminal record check for licensing purposes at least once every 5 years

Click here to see the list

If you are currently a registered/certified professional for which a BC Solicitor General CRC is part of your valid registration/certification, we accept a copy of your valid certification (#1 above) in lieu of the CRC.

Instructions for obtaining a CRC:

Go to: https://justice.gov.bc.ca/eCRC/home.htm
Use Access Code: ELE8TNX4ZY and click “Continue” (The access code provided is unique to SelfDesign, and will only provide a BC Solicitor General CRC for working with children and vulnerable adults)
B.C. residents who have lived in the province for at least six months must use a BC Services Card to submit an online Criminal Record Check
Follow the instructions on the BC Services Card App on your mobile phone to set up the app and have it confirmed to you via email, then you are ready to use it for your CRC application
Follow the instructions on the website link provided

Use the same process above to access the online application, follow the instructions, and it will take you to the page where, if you have one, you can:
- click on "Share the result"of a completed record check if you already have a CRC that is still current and valid filed with another organization (within the last 5 years)

If you do not have a BC Services Card, or if you are from out-of-province, or if for any other reason you cannot complete the CRC online, please contact crimcheck@selfdesign.org to complete your application manually.

Criminal Record Check *

CRC is included in Professional Certification/Licensing.
CRC on file with SelfDesign from a previous year (good for 5 years)
CRC (or CRC receipt of submission as confirmation of application)
I have emailed crimcheck@selfdesign.org for help with this.

Upload File

Click or drag a file to this area to upload.

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: Driver's License and Proof of Insurance.

Please note that $5,000,000 Third Party Liability Automobile insurance is required on any vehicle transporting a SelfDesign learner. Please confirm whether you will be transporting SelfDesign Learners below:

Will you be transporting a SelfDesign Learner? *

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

Upload Files

Click or drag files to this area 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 *

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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 *

Arts (Art and/or Art Therapy)
Arts (Music and/or Music Therapy)
Arts (Performing Arts, Theatre)
Behavioral Intervention
Counselling and/or Consulting
Psychological Assessments
Equine Experience
Movement-related (sports, physical education)
Occupational Therapy
Speech and Hearing Therapy
Other Professional Therapy (Physio, Massage, Acupuncture, etc.)
Specialized Academic Support and/or Tutoring
Other

Check all that apply

Other

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

Click or drag a file to this area to upload.

Document 2

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

If at any time an additional individual is engaged to work with a SelfDesign learner, please notify us - a CRC must be obtained for that individual prior to working with a SelfDesign Learner.

When you apply for a CRC, please forward a copy of your CRC processing receipt so that we know when the CRC is underway.

Governing Bodies and Regulated Professions: Members of the listed governing bodies are required to undergo a CRRP criminal record check for licensing purposes at least once every 5 years

Click here to see the list

Instructions for obtaining a CRC through the Ministry of Justice:

Go to: https://justice.gov.bc.ca/eCRC/home.htm
Use Access Code: ELE8TNX4ZY (The access code provided is unique to SelfDesign) and click “Continue”
B.C. residents who have lived in the province for at least six months must use a BC Services Card to submit an online Criminal Record Check
Follow the instructions on the BC Services Card App on your mobile phone to set up the app and have it confirmed to you via email, then you are ready to use it for your CRC application
Follow the instructions on the website link provided

Use the same process above to access the online application, follow the instructions, and it will take you to the page where, if you have one, you can:
- click on "Share the result"of a completed record check if you already have a CRC that is still current and valid filed with another organization
If you do not have a BC Services Card, or if you are from out-of-province, or if for any other reason you cannot complete the CRC online, please contact crimcheck@selfdesign.org to complete your application manually.

Criminal Record Check *

CRC is included in Professional Certification/Licensing.
CRC on file with SelfDesign from a previous year (good for 5 years)
CRC (or CRC receipt of submission as confirmation of application)
I have emailed crimcheck@selfdesign.org for help with this.

Upload File

Click or drag a file to this area to upload.

Document 3

Driver's License and Proof of Insurance.

Will you be transporting a SelfDesign Learner? *

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

Upload File

Click or drag files to this area 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 *

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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 *

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 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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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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