ABA BCBA Supervisor Contract Fall 2016

Date Date / MM / DD YYYY
BCBA Supervisor Name BCBA Supervisor Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email Address

You may be contacted by a representative of the Sage Colleges to verify student participation or other details.
Phone Number Phone Number - ### - ### ####

You may be contacted by a representative of the Sage Colleges to verify student participation or other details.
BCBA Certificant Number
Name of Practicum Student Name of Practicum Student First Last
Email Address of Practicum Student.
Please use college email address (ex: [email protected])
Semester of practicum
Upload Resume

Attach Files

Please upload a current resume/CV in .doc, .docx, or .pdf format.
Upload BACB Supervisor Approval Information Form.

Attach Files

Please upload a completed BACB Supervisor Approval Information Form. The student has been provided with this form, and additionally, it is listed on our website under Supervisor Information on the Supervisor Resources and Forms page. [ http://www.sage.edu/academics/esteves-school-of-education/applied-behavior-analysis-programs/applied-behavior-analysis-practicum-forms/ ]
I have taken the BACB required supervision course and module.

I have taken the BACB required supervision course and module. I attest that I am eligible to provide supervision to BCBA candidates.
Payment Option

Payment Option Supervision is not part of my standard occupational duties, and I will be accepting the stipend. Supervision is part of my standard occupational duties, and I will not be accepting the stipend. Supervision is part of my standard occupational duties, and my agency will be accepting the stipend.

At the end of the semester you will apply for payment at https://www.sage.edu/academics/esteves-school-of-education/applied-behavior-analysis-programs/applied-behavior-analysis-practicum-forms/
Thank you once again for your participation in the education of our students. By signing this document, you attest to the validity and truthfulness of the information supplied in this contract and that the relationships between the hosting agency, the student and the BCBA Supervisor may proceed in compliance with BACB regulations and the program rules set by The Sage Colleges.
By electronically signing my name below, I, the undersigned, certify that to the best of my knowledge, the information provided in this contract is correct, and I have read and will adhere to the terms provided on the Supervisor Resources and Forms page [http://www.sage.edu/academics/esteves-school-of-education/applied-behavior-analysis-programs/applied-behavior-analysis-practicum-forms/]

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.