Collaborative Education Alternative Program
School District No. 69 Qualicum
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140 Renz Road, Parksville, BC, V9P 1E8| Phone: 250-248-2969| Contact Us
8-12 Service Provider Approval Form

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Name of Student *
First, Last Name
Current Grade Level *
CEAP Teacher Name *
First, Last Name
Parents-Guardians *
First, Last Name
Parent Contact Phone: *
Parent Contact Email *
Provide a valid email address for us to contact you.
Lesson Type/Activity provided by the service provider (NOTE: if RDN related be sure to include A) level of lessons if applicable and B) 5 digit activity code from Active Living Guide) *
Please provide a short description of the activity provided by the service provider.
Start Date *
Select a date from the calendar.
End Date *
Select a date from the calendar.
Number of lessons/sessions *
Please list the total number of times the student will attend the activity.
Total Cost to be allocated from funds *
Provide the total cost to be paid out from the student's available funds. (Payment requires: Approval of teacher + Available funds)
Curriculum Goals or Skills connected with this request for activity support *
Please define the curriculum/subject area and provide a list of goals, skills or outcomes expected through participation in this activity.
Service Provider Name *
Select the Name of the service provider from the list. For service providers not on the list, please contact our office at (250) 752-5628. All Service Providers must complete a contract with CEAP in order to be listed as a valid CEAP service provider.
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