Agency Referral Form

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KEEN London Agency Referral Form

KEEN London supports children aged 5–11 with additional needs across London, through a free two-year programme of inclusive sport, physical activity and creative sessions. This form is for professionals — such as teachers, SENCOs, social workers, or health practitioners — making a referral on behalf of a child they know.

Please provide as much information as possible. The information requested helps us assess eligibility and better support the young person from their first session.

If you are having difficulty completing this form, or would like assistance, please contact us on 0207 686 3172 and we will be happy to help.

Due to high demand, we maintain a waiting list. Children are added on a first-come, first-served basis once eligibility is confirmed, and we may prioritise based on age, urgency of need, time already on the waiting list, whether the child receives other out-of-school support, and the current status of the service. We will keep families updated on waiting list status by email, letter or phone.

About You, the Referrer

Your Name

Professional Role

Organisation

Phone Number

Email Address

Your Current Relationship to the Child

e.g. school-based, allocated social worker, involved since [date]

What Work Have You Done With the Child?

This helps us understand the support already in place and avoid duplicating it.

Does the Parent/Carer Know About and Agree to This Referral Being Made?

YesNoKEEN London cannot progress a referral without parent/carer agreement.

Do They Consent to KEEN London Contacting Them Directly to Progress This Application?

YesNoKEEN London will confirm data protection consent directly with the parent/carer once contact is made this is separate from the agreement above.

Information about the Athlete (young person)

Which is their preferred session?

Lambeth - Saturdays (Age 5-11)Hackney - Saturdays (Age 5-11)Wembley Park - Saturdays (Age 5-11)

Athlete Firstname

Athlete Surname

Date of Birth (dd/mm/yyyy)

Athlete Gender

Athlete Religion (this is confidential and used for monitoring purposes only)

Athlete Ethnicity (this is confidential and used for monitoring purposes only)

Address

Town / City

County / State

Postcode

Athlete School

Please list below the disabilities/additional needs/health conditions of the athlete. Please enter as much information as possible.

Is the athlete verbal, pre-verbal or non-verbal?