Referral form: LIFT, Safer Space, STEP, Westminster and Community Groups programmes

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Programmes
Click here for information on our different programmes and their acceptance criteria.



Permissions and policies



CHILD












MAIN CARER 









OTHER FAMILY MEMBERS








FAMILY - Further details 







RERERRER'S INFORMATION







School details



 

OTHER PROFESSIONALS INVOLVED WITH CHILD OR FAMILY









FURTHER REFERRAL INFORMATION





 


Yes No Don't Know






MONITORING INFORMATION
The following themes are challenges faced by some of the families referred to Chance UK. These themes are monitored by Chance UK and do not determine whether a child is eligible for the mentoring programme. 





PRIVACY NOTICES



Medical Form and Consent form

Basic Information

Medical Details



Food Allergy and Dietary Requirements

Children taking part in the 12 week workshops will be given a snack on arrival and will have the opportunity to cook and eat freshly made food.

In order to keep them safe and ensure the food used meets their dietary requirements we will need some additional information.



Consent to take child off site in session 11 to visit supermarket


Photography and filming consent form

In accordance with our child protection policy, we will not permit photographs, video or other images of young people to be taken without consent. If the child is under 16, consent must be obtained from a parent / carer.

Chance UK will take all steps to ensure these images are used solely for the purposes for which they are intended. If you become aware that these images are being used inappropriately, please inform us immediately.

Permission to Photograph and or video child

Please complete the declaration of consent, sign and date at the bottom of the form
Please sign and date at the bottom of the form

Declaration of consent - parent / carer of child under 16



Thank you for completing the referral!


For monitoring purposes, we will need to complete a Strengths and Difficulties Questionnaire with both the main carer and a teacher. We will be in touch to do this once the referral has been accepted.