Confidentality/communication Agreement For Non-Sbcsc Employees (Page 4 of 5) in pdf

Confidentality/communication Agreement For Non-Sbcsc Employees Page 4

SPECIFIC ACTIVITY(S) PERFORMED BY OUTSIDE SERVICE PROVIDER:

• _________________________________________________________________

NATURE AND FREQUENCY OF DOCUMENTATION/COMMUNICATIONS PLAN:

• _________________________________________________________________

AGREEMENTS:

A. Parent/Guardian Agreements

• I authorize the SBCSC to disclose my child’s education records (and information

derived from those education records) to the Outside Therapist/Consultant for the

purposes described above.

• I understand that: (1) I have the right not to consent to the release of my child's

education records; (2) I have the right to receive a copy of such records upon request;

and (3) this consent shall remain in effect until revoked by me, in writing, and delivered

to the SBCSC, but that any such revocation shall not affect disclosures previously made

by the SBCSC prior to the receipt of any such written revocation.

• I understand that the SBCSC may, within its sole discretion, terminate this partnership

at any time for any reason.

B. Outside Therapist/Consultant Agreements

• I understand that I am not an agent or employee of the SBCSC for any purposes

whatsoever.

• I authorize the SBCSC to obtain the following information about me: (1) an “expanded

criminal history check” as defined IN Ind. Code 20-26.2-1.5(2)); (2) a search of the

national sex offender registry maintained by the United States Department of Justice;

and (3) a detailed background history including all prior employment and volunteer

positions. I understand that if, during the course of my relationship with the SBCSC, I

am arrested, charged, or convicted in Indiana or in any other jurisdiction of any of the

offenses listed in Ind. Code 20-26-5-11, as may be amended from time to time, I agree

to notify the SBCSC no later than two (2) business days after such arrest, charge or

conviction.

• I understand that, during the course of performing the services contemplated in this

document, I may have occasion to view or access student education records and to

[Copies: Parent, Cum, TOR, Outside Therapist/Consultant, Special Education Dept

8/07/2015

Page 4 of 5

Confidentality/communication Agreement For Non-Sbcsc Employees Page 4