SPARK - Referral Form

Nelson Mandela Public School - Supporting Student Success

The SPARK program is an exciting and influential program offered to the students at Nelson Mandela P.S. to support student learning & achievement, mental health and overall well-being. SPARK focuses on using physical activity to support brain function and improving learning in the classroom.

Referral Form: Please fill out below and submit

Student Name:________________________

Referring Teacher Name:________________________________________

Please check-off following SPARK criteria applicable to referred student

_____ difficulties maintaining focus and attention in class

_____ hyperactive characteristics in class

_____ consistent behavioral issues in class and on playground

_____ difficulties in social interactions amongst peers

_____ consistent display of boredom, lack of motivation and effort in class

Additional information applicable to student

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