Program Support Partner Application

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

Program Information
Program Type	☐ Infant	☐ Toddler	☐ Preschool	☐ Before School	☐ After School
Days Requesting Support	☐ Monday	☐ Tuesday	☐ Wednesday	☐ Thursday	☐ Friday	Number of Hours Requesting: Enter text.
Number of staff in Group: Enter text.	Daily Average number of children: Enter text.	Number of children with ELSP: Enter text.

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 children’s attendance	Enter text.	Frequency	Enter text.
Intensity
☐	The physical environment increases the level of need and impacts on the ability to keep children safe, challenges cannot be addressed by environmental adaptations	Enter text.	Frequency	Enter text.
Intensity
☐	An extraordinary level of adult intervention is needed due to 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 children’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, interaction & 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