Parent initiated service provider for students with disability request form

Step 1 of 3

Parents use this form to request access for external service providers, such as therapy services, for their child during school hours.

Notes:

This form relates to external service providers only. It is not required for the Department of Education’s specialist schools and their teaching staff, who may provide services on school sites.
Complete a separate form for each provider that you are requesting access for.
Your school will consider your request in line with the:
- duty of care to staff and students
- student’s educational and wellbeing needs
- ability of the student to access the service outside school hours or through existing Department programs
- provider’s use of school facilities and resources.
Your school may ask you or the provider to provide additional information. It is your responsibility to make sure this information is provided.

Students Details

Students Name

First

Last

Date of Birth

Parent Details

Parent Name (1)

First

Last

Contact Phone Number

Parent Name (2) Name (if applicable)

First

Last

Contact Phone Number

Confidentiality

All information provided in this Application for Parent initiated service provider will be treated confidentially. The information provided is used to determine whether your Application for Enrolment can be accepted.
The process also assists SELDC with addressing any needs for your child if the application is accepted and to comply with legal requirements or ministerial directions.

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Parent initiated service provider for students with disability request form

Parents use this form to request access for external service providers, such as therapy services, for their child during school hours.

Students Details

Parent Details

Information about the support to be provided

Provider Details

Confidentiality