CBA Authorization for Intervention, Therapy, and Extracurricular Activities Form

Please complete this form if you would like your child to participate in activities during school hours with a non-CBA employee.

By completing this form, you are giving permission for the named individual to remove your child from their scheduled CBA program in order to participate in the specified activity. Non-CBA employees must pass a background check prior to working with students. ALL REQUESTS ARE SUBJECT TO ADMINISTRATOR APPROVAL. You will be notified by email when your request has been reviewed. Please allow 1-2 weeks for background checks, administrator approval and the scheduling process. Following approval, a school representative will contact the professional to schedule an appropriate time to work with your child. Please note, in order to keep up with their regular classwork, students should make up any missed assignments afterschool at home.

Student's First Name(Required)

Student's Last Name(Required)

Student Grade Level(Required)

Parent/Guardian Name(Required)

Phone(Required)

Email(Required)

Outside Provider Information

Type of Activity (Ex: Speech-language therapy, occupational therapy, counseling, etc.)(Required)

Provider name(Required)

Organization/Company

Phone(Required)

Email(Required)

Requested start date(Required)

Requested end date(Required)

*If the service or activity continues for more than a year from the date it is requested, the form must be renewed.

Number of days requested per week

Preferred time of day (Requested time is not guaranteed, due to limited space.)

Comments

PLEASE SIGN TO GIVE CONSENT. I am aware that while participating in this activity, my child will NOT be supervised by a qualified staff person employed by Charleston Bilingual Academy. While the school may provide a location for the outside provider to work with my child, the named individual will be responsible for the safety and supervision of my child.(Required)

Parent/Guardian Signature