The Hackney Pirates

Young Pirate Referral Form

This form allows you to refer students to our after-school program, and is used by The Hackney Pirates staff to assess the suitability of the young person being referred. 

Some notes on the process - 

1. The Young Person's place is only confirmed once we have contacted you with referral approval confirmation. 

2. Please do not inform the young person or contact their parents at this stage. This will avoid disappointment if we decide that the child does not meet our referral profile. 

3. The information below should be provided by the class teacher (Primary) or English teacher (Secondary), or the potential Young Pirate (with support from the Pirate Liaison, if needed).

4. Data Protection: Please do not submit sensitive information or Young Person contact details via this form. This form is for the assessment of access and learning needs only. If you are in doubt please contact The Hackney Pirates. 

5. Following the referral being approved, we will begin the registration process with parents.

If you have any questions, please get in touch with your contact at The Hackney Pirates on

You can also email or call 07912 178037 (Primary) or 07834 372257 (Secondary) 

Many thanks for your support, and we look forward to working with your students!

1. Your Details

This must be a valid email address - please use yours if you're unsure

2. Child's Details

3. Child's Eligibility

4. Child's Attainment 

Thank you for completing this form!

Please press the Submit button below to send your referral to us, and to complete another referral (optional)