YMCA TG Woolwich Youth Referral Form

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Referrer Details

Referral Agency

Referrer name

Agency contact details

Address line 1

House/flat number & street

Town/City

Post code

Phone

Consent from parent/carer if under 16

Any young person aged 13-15 who is deemed Gillick competent by staff doesn’t have to seek parental consent if there is a reason they wish not to do so Update Youth consent record: Referrer Consent with Referral Agency, Agency Contact, Date form submitted and fields below If yes, next 4 questions

Consenting parent/carer name

Consent from young person if over 16 (or if 13-15 and parent should not be contacted)

Any young person aged 13-15 who is deemed Gillick competent by staff doesn’t have to seek parental consent if there is a reason they wish not to do so

Date of consent

Method of consent

Reason for referral

Please include as much detail as possible

Areas of concern

Please select any relevant areas and include further details in the question above if necessary.

To select multiple options, hold down the ctrl key

Young Person details

First name

Last name

Date of birth

Gender

Ethnicity

Religion

Contact details

Address line 1

House/flat number & street

Town/City

Post code

Email (of young person)

Phone number (of young person)

Status

School/College attended

Other School/College

How did you find out about YMCA Woolwich Youth and/or Young Greenwich?

Other (please specify)

Medical/Dietary Information

Any known medical conditions?

i.e.asthma, diabetes, heart condition, back pain etc.

Medical condition(s) details

Any known allergies?

Food allergies and any other allergies e.g. bee sting

Allergies details

The level of reaction and actions required i.e. EpiPen

Takes regular medication?

Medication details

Please include name, dosage and frequency

Any special need or disability?

Special needs & disability

Please select from list and add details below

Level of support

Please summarise the level of support needed to suit additional needs

Any other additional needs?

In addition to what has already been stated

Additional needs

Please provide details of any additional needs diagnosed or not (i.e. anxiety, struggles with reading/writing, autism, ADHD, struggles to concentrate)

Any dietary requirements?

Dietary requirements

Any other concerns

Any other emotional, social, educational, health concerns or support needs for you/your child or family?

Parent/Carer Details

Parent/Carer 1

Parent/Carer Name

If you don't know their name, please enter "Mother of [young person name]" for example

Relationship to young person

Same address as young person?

Address & post code

If different from address of young person

Mobile

Home phone

Do they have parental responsibility?

Are they an Emergency Contact?

At least 1 emergency contact must be provided. If this parent/carer is not an emergency contact, a new section will appear where you must enter a second parent/carer who is.

Would you like to add details of a second Parent/Carer?

Parent/Carer 2

Parent/Carer Name

If you don't know their name, please enter "Mother of [young person name]" for example

Relationship to young person

Same address as young person?

Address & post code

If different from address of young person

Mobile

Home phone

Do they have parental responsibility?

Are they an Emergency Contact?

Data Protection & Privacy

YMCATG are commissioned by CACT to provide certain youth and children’s services. As such YMCATG has a contractual, and in some cases legal obligation, to pass certain personal information of users of these commissioned services to the data controller. More information on the sharing of data can be found in our Privacy Notice for Youth Services at www.ymcatg.org/privacy-notice-youth/ or on the CACT website cact.org.uk/policies.

For more information contact us on 01708 766211 or dpo@ymcatg.org.

We ask that you keep us informed of any changes to the details contained in this registration form. Periodically we may ask you to confirm your details for our records.

I confirm that the information given in this form is accurate, true and complete

Yes

First name no special characters

Last name no special characters

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