LOOK UK - Mentoring Project Referral Form

Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Thank you for taking the time to refer a young person to LOOK. Please complete as much as you can below, we understand that you may not have all of the details but the information will really help us process the enquiry. An individual can be referred to LOOK UK's Mentor Project by a parent or carer, or a professional working with the individual. We also welcome people to refer themselves directly to us if they are aged over 13.

Best Wishes
LOOK UK

Referrer's Contact Details

First Name

Phone number

Postcode

Organisation Name

Job Title

Consent

I would like to receive the LOOK UK newsletter via email to keep up to date with the latest news and events.

YesNo

I consent to my data being stored in line with LOOK UK's privacy policy.

You may withdraw your consent at any time.

Last Name

Email Address

What is your relationship with the young person you are referring?

Young Person's Details

Young Person's First Name

Young Person's Date of Birth

Young Person's Phone Number

Young Person's Last Name

Young Person's Postcode

Young Person's Email Address

Visual Impairment

Eye Condition

Registered as..

Does the young person have any additional disabilities / health conditions?

Please describe

Education & Support

Does the young person have an EHCP?

Name of School/College (if applicable)

Is the young person currently in further education and considering University as their next step?

Reason for Referral

Parent/Carer information

Parent/Carer First Name

Parent/Carer Last Name

Parent/Carer Mobile Number

Parent/Carer Email Address

Relationship to the young person

Parent/Carer Postcode

This parent/carer consents to their data being stored in line with LOOK UK's privacy policy. They may withdraw consent at any time.

Save my progress and resume later | Resume a previously saved form

Contact Information