San Bernardino County Superintendent of Schools REGIONAL OCCUPATIONAL PROGRAM Affiliation Agreement Request Form (Dental Program) INSTRUCTIONS District to: 1. Complete the information at the bottom of this page and the attached Affiliation Agreement. 2. Secure all required signatures, scan and email to: pam.skinner@sbcss.net SBCSS ROP will: 1. Verify that an agreement doesn’t already exist for the requested site. 2. Verify that the course is approved for community classroom. 3. Email the signed agreement to SBCSS Purchasing/Contracts for processing. SBCSS Purchasing Contracts will: Sign the agreement, assign an agreement number, and email a fully-executed electronic copy to: SBCSS ROP (Pam Skinner). The email address(s) below. The affiliate’s email (if listed on page 2). Important: A student cannot be placed at a site until a fully-executed agreement is in place. CONFLICT OF INTEREST: The undersigned, Requestor and Department Manager/Coordinator, hereby certifies that they have no financial, personal relationship or other interest (i.e. is not an officer, member, partner, shareholder or director) in the subject of this recommendation and placement of said student. School District: Teacher #1: District Coordinator: Email Address: Teacher #2: Signature: Email: Teacher #3: Email: Agreement No. _______________________ OFFICE OF SAN BERNARDINO COUNTY SUPERINTENDENT OF SCHOOLS REGIONAL OCCUPATIONAL PROGRAM AGREEMENT FOR AFFILIATION (DENTAL PROGRAM)
San Bernardino County Superintendent of Schools REGIONAL OCCUPATIONAL PROGRAM Affiliation Agreement Request Form (Dental Program) INSTRUCTIONS District to: 1. Complete the information at the bottom of this page and the attached Affiliation Agreement. 2. Secure all required signatures, scan and email to: pam.skinner@sbcss.net SBCSS ROP will: 1. Verify that an agreement doesn’t already exist for the requested site. 2. Verify that the course is approved for community classroom. 3. Email the signed agreement to SBCSS Purchasing/Contracts for processing. SBCSS Purchasing Contracts will: Sign the agreement, assign an agreement number, and email a fully-executed electronic copy to: SBCSS ROP (Pam Skinner). The email address(s) below. The affiliate’s email (if listed on page 2). Important: A student cannot be placed at a site until a fully-executed agreement is in place. CONFLICT OF INTEREST: The undersigned, Requestor and Department Manager/Coordinator, hereby certifies that they have no financial, personal relationship or other interest (i.e. is not an officer, member, partner, shareholder or director) in the subject of this recommendation and placement of said student. School District: Teacher #1: District Coordinator: Email Address: Teacher #2: Signature: Email: Teacher #3: Email: Agreement No. _______________________ OFFICE OF SAN BERNARDINO COUNTY SUPERINTENDENT OF SCHOOLS REGIONAL OCCUPATIONAL PROGRAM AGREEMENT FOR AFFILIATION (DENTAL PROGRAM)
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