K to 7 - Service Provider Approval Form
Please familiarize yourself with all of the policies/guidelines pertaining to Student Learning Support Funding by visiting this page.
Please complete ALL fields​​ below. The form cannot be submitted unless all required fields are completed. Successful submission will take you back to the main site page.


Name of Student *
Current Grade Level *
CEAP Teacher Name
Parent Contact Phone: *
Parent Contact Email *
Service Provider Name *
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 *