YMCA St Paul's Group Youth Services Referral Form

Referral date

Personal Details

Title

First Name

Last Name

Select Project

Preferred name

Phone number

Mobile number

Young Person's Address

Please provide the postcode as a minimum

Address Line 1

Address Line 2

City

County

Postcode

Date of birth

Is the young person under 16?

Parent/Guardian

Parent/Guardian's name

Relationship Type

Contact Mobile

Contact Phone

Contact Email

Contact Address

Verbal consent for Youth Services given

Gender

Gender identity

Ethnic origin

Preferred language

Religion

Looked after child

Support Needs

School / College

Next of Kin

Next of Kin's name

Relationship Type

Contact Mobile

Contact Phone

Contact Email

Contact Address

Timeline

Self Referral?

Referrer details

Please include details of the local authority / charity / other professional organisation who is making this referral

Referral Agency email address

Agency telephone

What sessions are you interested in?

Consent

UK General Data Protection Regulations (UKGDPR) / Data Protection Act 2018 (DPA)

Information collected from you will be added to our database. We may use this for administrative purposes in providing our range of services, and for communication with you.

In compliance with the UKGDPR/DPA, all information will be treated confidentially and will not be shared with any other organisation without your explicit and informed consent.

For further information on how we hold and use your personal data, please ask for a copy of our full Privacy Policy

Data Sharing Consent

Contact Information