Tottenham Futures Referral Form

Page 1

REFERRAL ORGANISATION DETAILS

Organisation Name

Referred By: First Name

Referred By: Last Name

Organisation Address

Organisation Post Code

Email

Telephone

Mobile

Page 2

CARER/PARENT DETAILS

Carer/Parent Name

Carer/Parent Mobile

Carer/Parent Email

Relationship to participant

CHILD/YOUNG PERSON DETAILS

First Name

Last Name

Mobile

Address

Date of Birth

Gender

Other gender

Ethnicity

Asian Other

Black Other

Mixed Other

White Other

Other Ethnicity

Does the child/young person have additional support requirements? Please tick the appropriate box (this can include learning, behavioural and/or mental/emotional support requirements).

YesNoUnknown

If yes, please tick all the boxes that apply. Hold 'ctrl' button to select multiple options.

Other support requirements:

Is the child/young person supported by an EHCP?

YesNoUnknown

Medical Condition

Medication

Is the child/young person known to the Youth Justice Sercice?

YesNoUnknown

If the Lead Professional supporting the child is not completing this form please share name and contact details below.

Name of school/6th form/college/training/apprenticeship provider

NEET (Not in Education, Employment or Training?) Hold 'ctrl' button to select multiple options.

Page 4

DATA PROTECTION:

A data protection impact assessment has been carried out to assess the specific processing activity.

All personal data received into the Foundation from the Referral organisation will be via the secure electronic transfer.

Appropriate security measures have been applied to the storage and associated processing activities of the personal data.

The personal data will be electronically erased from the secure data repository in accordance with the Foundation's data retention policy.

For any additional information regarding the information processing activity please contact our Data Protection Officer by emailing personaldata@tottenhamhotspur.com

Image and case study consent

Images (photographs and/or video) may be taken on programmes and used to promote Tottenham Hotspur Foundation (The Foundation) or Tottenham Hotspur Football Club (The Club). Case study questionnaires or interviews may be conducted to celebrate achievements of the participants and demonstrate the positive impact of the Foundation and Club in the community.

These case studies and images may be used in internal reports and also appear in the public domain: in our printed publications (such as matchday programmes), on our website tottenhamhotspur.com, local or national media and used for other promotional material purposes by the Foundation and the Club.

All images will show participants in a positive manner. The Foundation will not permit case studies or images of participants to be used without their consent, or where appropriate, the consent of their parents or guardians.

I have reviewed the below attached terms and I give permission for myself and/or my child(ren) to be photographed and/or filmed and/or recorded for this event by the Foundation. Please find here the Consent Terms

Code of Conduct

Please read our Code of Conduct here.

I confirm I have read and understood the Code of Conduct

I hereby give permission for my child(ren) to travel home from the Event independently and I acknowledge that the Foundation are not responsible for my child during such travel.

KEEPING IN TOUCH

We would like to tell you more about the impact we’re having in the community and ways you can get involved, including donating, fundraising, events and campaigns.  

Tick here if you would like to hear about our wider work via email.

Comms Opt-in Date

To unsubscribe from our mailing list, please email: foundationsupporter@tottenhamhotspur.com  

If at any point you opt out of Tottenham Hotspur Foundation news, you will not be opted out from any communications that you may have separately opted in to receive from Tottenham Hotspur Football Club.  

For more information on how we process your personal data, please refer to our Privacy Notice.