K to 7 - Service Provider Approval Form - Collaborative Education Alternative Program

Collaborative Education Alternative Program

Qualicum School District

Located in Winchelsea Learning Centre

140 Renz Road, Parksville, BC, V9P 1E8| Phone: 250-248-2969| Contact Us

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.

Important:

All requests must be discussed with the teacher. This form goes to the teacher, who must approve it and forward to our office.
Parents and service providers will receive a copy of the approved form by email, indicating the amount approved.
Only service providers listed on this form are approved.If you do not see the desired service provider in the list on the form, please have them contact our office, in order to register.
All requests must be submitted prior to May 1 and invoices received by our office by June 15th.
ADDITION FALL 2015: For Lesson Type/Activity provided by the service provider box: if RDN related be sure to include A) level of lessons if applicable and B) 5 digit activity code from Active Living Guide)

Name of Student *

First, Last Name

Current Grade Level *

CEAP Teacher Name

First, Last Name

Parents-Guardians

First, Last Name

Parent Contact Phone: *

(xxx) xxx-xxxx

Parent Contact Email *

Provide a valid email address for us to contact you.

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.

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 *

End Date *

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.

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