Individual Support Partner Application

Child Care Program Information
Child Care Program	Child Care Supervisor/Director
Phone Number	Email
Early Childhood Educators/Child Care Workers	Resource Consultant

Individual Child Referral Information
Child’s Name	Enter text.	Date of Birth	Enter text.
Program Child Attending	☐ Infant	☐ Toddler	☐ Preschool	School Age ☐ Before School ☐ After School
Days of Attendance	Monday ☐	Tuesday ☐	Wednesday ☐	Thursday ☐	Friday ☐
Hours of Attendance	Enter text.	Enter text.	Enter text.	Enter text.
Hours Requesting per day	Enter text.	If child attends School Age Program: Enter text.	Will child be attending PD Days or March Break? Enter text.	Hours requesting: Enter text.
Number of staff in group: Enter text.	Number of children: Enter text.	Currently at full capacity: ☐Yes ☐ No

Rationale for Support
Check off all that apply	Reason you are applying for SP	Describe in detail the challenges, frequency/intensity of the challenges	Rate Frequency (1 being Rarely and 5 all the time) Intensity on a scale of 1-5 (1 being mild and 5 intense)	If approved, how will funding be utilized to support these challenges?
☐	Increased level of adult assistance for positioning, mobility and use of specialized equipment frequently during child’s attendance	Enter text.	Frequency	Enter text.
Intensity
☐	The physical environment increases the level of need and impacts on the ability to keep the child safe, challenges cannot be addressed by environmental adaptations	Enter text.	Frequency	Enter text.
Intensity
☐	An extraordinary level of adult intervention is needed due to the child’s medical needs which require ongoing monitoring and administrative responsiveness	Enter text.	Frequency	Enter text.
Intensity
☐	Injurious behaviours to self and/or others (peers, Staff) high frequency, serious risk	Enter text.	Frequency	Enter text.
Intensity
☐	Educators require support to follow through with strategies/recommendation from the child’s ELSP.	Enter text.	Frequency	Enter text.
Intensity

What are you currently doing to alleviate above mentioned challenges with regards to the adaptions to environment, activities, interactions & expectations etc.
Enter text.
If approved what is the plan to build capacity in your program so support partner funding is no longer required.
Enter text.

Any Other Information you would like to share: (attach additional page if required)
Enter text.

CCSS Other Required Information:
If required, when is the most appropriate time and day of the week for CCSS Supervisor to observe:	Days of Week: Enter text. Time of Day: Enter text.
Most appropriate time and day of the week for CCSS Supervisor & RC meet with educators and/or Child Care Supervisor to discuss Recommendations:	Days of Week: Enter text. Time of Day: Enter text.

This above information has been completed in collaboration with Educators, Child Care Supervisor and Resource Consultant.
Date of Referral:	Enter date.
Educator Name:
Print	Signature
Child Care Supervisor Name:
Print	Signature
Resource Consultant Name:
Print	Signature