Step Three-sign a contract

Step Three: Here is a sample contract you might wish to use or change to meet your needs.

The form you see here has been condensed, you may print a copy of the form: Step 3 contract.doc (55296 B)

Please note that it is not legally binding.

Name of person to receive respite care:

Describe the care and activities required
In the home	Out of the home	Additional comments



Medication requirements (if required to give medication):

Rate and frequency of pay
Hourly
Daily
Overnight rate
Flat 24 hour rate
When and how often the Respite contractor will be paid?

Scheduling	Respite Contractor	Contacting Me
Best way to contact
Times to contact
Hours notice to be given to cancel
Hours notice to be given to book

Expenses (activity fees; for example, cost of transportation, admission to the movies, meals while out, etc)

Covered by us

Not covered by us

(to be paid by Respite contractor)

Comment

Smoking

In our home

In the Respite contractor’s home

In the community

In the vehicle:( smoking is against provincial law when transporting those under the age of 16)

Yes or no

As a self-employed independent Respite contractor,

I am responsible for reporting my own income and to make appropriate Canada Pension Plan, Employment Insurance premiums, Income tax and GST/HST remittances if needed.
I will carry vehicle liability insurance if I am providing transportation.
I will carry my own liability insurance if I consider it to be needed.

The family has no responsibility for remitting all necessary statutory payment and remittances. For example: a T4 slip, vacation pay, provincial medical plan, Workplace Safety and Insurance coverage, Employment Insurance premiums, higher rate of pay for overtime hours, severance pay etc.

When providing the above care in this capacity, the self-employed independent Respite contractor is not an employee of: Access Better Living Inc., Cochrane Temiskaming Extend-a-Family, Cochrane Temiskaming Resource Centre, Cochrane Temiskaming Children’s Treatment Centre, Community Living Iroquois Falls, Community Living Kirkland Lake, Community Living Temiskaming South, Community Living Timmins, Cochrane Community Living, Kapuskasing and District Association for Community Living, Hearst Community Living, Child and Family Services of Timmins and District/autism program.

Ending the contract	Days notice will be given
If the Respite contractor wishes to end the contract
Should Parent/guardian wish to end the contract
However; Abuse (verbal, physical, emotional, financial) or suspicion of abuse will result in an immediate end to this contract.	immediate

Agreement: This agreement is signed in respect of each person’s confidentiality
I agree with all of the above	Date:
*Contract is agreed to from	Date:	To date:
Respite contractor signature
Parent/guardian/caregiver’s signature
Signature of person receiving care

*It is suggested that the contract is reviewed and re-signed yearly.

Provincial Respite Services Network 2018 Update