81 501 2012 09
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C
HILD CARE SUPPORT REFERRAL FORM (CCSF) 2012
Contract agreements: (please refer to the Child Care Support Guidelines)
The Child Care Centre agrees to the following:
1. The addition of CCSF and/or IRS services in the child care program.
2. To hire CCSF staff so that regular staff can provide a higher level of support to the child names in the
contract.
3. To provide direct supervision to CCSF staff.
4. Payment to CCSF staff according to typical pay schedule and rate indicated on request form.
5. Sign and submit documentation required for CCSF payment in a timely manner.
6. Involve and inform families in all aspects of IRS service.
7. Promptly communicate any concerns or questions to the Special Needs Resource staff and/or the Intensive
Resource staff.
8. On-going collaboration and consultation with the Special Needs Consultation service and/or Intensive Support
service regarding the child’s needs and progress.
9. Prompt notification and cancellation of CCSF staff or Intensive Resource staff when the child is absent.
Signature Date (dd-mmm-yyyy)
The Home Child Care Agency agrees to the following:
1. Knows about the IRS support request to the Home Child Care Provider listed on the form.
Signature Date (dd-mmm-yyyy)
The Home Child Care Provider agrees to the following:
1. The addition of Intensive Resource Support services in their home.
2. To involve and inform families in all aspects of IRS service.
3. To promptly communicate any concerns or questions to the Special Needs Resource staff and/or the
Intensive Resource staff.
4. On-going collaboration and consultation with the Special Needs Consultation service and/or Intensive Support
service regarding the child’s needs and progress.
5. Prompt notification and cancellation of IRS staff when the child is absent.
Signature Date (dd-mmm-yyyy)
Parent / Guardian agree to the following:
1. The addition of CCSF staff and/or Intensive Resource Support services in the child care program.
2. To attend initial planning meeting and subsequent review meetings.
3. To communicate with the child care Supervisor/Provider/Staff, Special Needs Resource staff and/or Intensive
Resource staff as deemed necessary.
4. To inform the Supervisor/Provider as soon as possible if child is going to be absent.
Signature Date (dd-mmm-yyyy) Signature Date (dd-mmm-yyyy)
Special Needs Resource staff agree to:
1. Organize the first planning meeting immediately after receiving notice that IRS has been approved.
2. Develop goals in partnership with parents, child care staff/provider and IRS staff as described in this
agreement.
3. Meet with the Child Care Centre/Provider, Intensive Resource staff and/or family regarding the child’s on-
going and changing needs.
4. Maintain active involvement with the child care program during the implementation of CCSF/IRS.
Signature Date (dd-mmm-yyyy)