Form C - Advice for External Therapy Provision FORM C - Advice for External Therapy Provision Please complete this form to authorise provision of therapy during school hours for your child. First Name * Last Name Email * Student Name * Therapy Details Speech Therapy (Agency and name of therapist) Occupational Therapy (Agency and name of therapist) Physiotherapy (Agency and name of therapist) Psychology (Agency and name of therapist) Other (please list) Requested location for therapy/service during school hours Location of therapy/service requested * Classroom Playground To be negotiated. Home* At therapy provider* *If your child will be undertaking therapy during school hours which is not at Cloverdale ESC then they will require Alternative Attendance Arrangement approval (as per Section 24 of the School Education Act 1999). The school will contact you to make these arrangements. Parent Acknowledgement ☐ Parent understands that principals may reconsider access for a provider at any time. ☐ Parent understands additional information about the decision making process is available on the Department of Education’s public website. ☐ Parent is responsible for communication with the provider including advising the provider if their child will be absent for the planned session ☐ Parent is responsible for communicating with the school to advise on any changes to provider, absence of provider or absence of their child. ☐ Parent understands the school will not cover any costs associated with the provider’s access to the student at school. ☐ Parent gives consent for the release and exchange of information between the provider and the school. Parent Acknowledgement * I have read the above and by checking this box acknowledge that I have understood and agreed. I confirm the above details and will notify the school if there are any changes. I understand that I will be notified if this application for therapy to occur during school hours (at school or at another location) is approved. * Undo Clear Write your signature above the line Submit Loading... Thank you for your submission. It has been received successfully. 180 Fisher StreetCloverdale WA 6105 Phone: 08 9438 7850 Contact the School
