8-12 Service Provider Approval Form

For complete information on policies and guidelines regarding Student Learning Support funding visit this page.

Please complete ALL fields​​ below. Once submitted. this form is automatically sent to the CEAP teacher, who approves the educational validity of the request by forwarding the form to our CEAP office. Our office will then inform the parent and the service provider of the availability of funding, and the activity can begin.


Name of Student *
Current Grade Level *
CEAP Teacher Name *
Parents-Guardians *
Parent Contact Phone: *
Parent Contact Email *
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) *
Start Date *
Select a date from the calendar.
End Date *
Select a date from the calendar.
Number of lessons/sessions *
Total Cost to be allocated from funds *
Curriculum Goals or Skills connected with this request for activity support *
Service Provider Name *