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.

Outside Provider Information

MM slash DD slash YYYY
MM slash DD slash YYYY
*If the service or activity continues for more than a year from the date it is requested, the form must be renewed.
Parent/Guardian Signature