Views External

Identity

Forename

Surname

DateOfBirth

Age

Demographic

Ethnicity

Gender

Address

Address1

Address2

Post Code

Contact

Emergency Contact Name

Emergency Contact Phone Number

Email Address

Relationship to YP

Doorstep Sport Impact Programme - Community Safety

Young Person in Youth Offending System

Lifestyle

Is the Young Person Eligible for Free School Meals?

TV VRU Referral Criteria

Current School Attendance Percentage

Refer Information

Name

Email Address

Organisation

Telephone Number

Consent

Guardian agrees to inform coaches should this change. (Under 16)

Agree Disagree

Young person agrees they are fit and healthy to lift weights

Agree Disagree

YP agrees to inform Coaches of any change in health (Over 16)

Agree Disagree

Guardian of YP gives permission for YP to lift weights

Agree Disagree

Young person agrees they are fit and healthy to Skateboard/Box

Agree Disagree

Guardian of YP gives permission for YP to Skateboard/Box

Agree Disagree

I consent to my data being used in Social Impact Reports.

Agree Disagree

I consent to TPPT taking and using photos for marketing purposes

Agree Disagree

Education Provider Information

School / College / Learning Provider - Name

School / College / Learning Provider - Contact Email

Details of most appropriate contact in school for the YP

Additional Assessment Information

Is YP involved in a problematic peer group?

Is YP associated with gang members?

Is YP excluded from school / education?

Name of JOS Worker

Has YP had a 'missing' episode?

Name of Social Worker

Please tell us if the YP is being supported by:

How would you describe YP's confidence at school?

Brief History

Please provide any other relevant background information

Health

Please provide details of any health related conditions of YP

Referral Information

Chances Referral Criteria

Low school attender/ attending on a part-time timetable/ in alternative provision/ excluded from school (therefore also at risk of NEET). Not in Education, Employment or Training (NEET) or At Risk of NEET Are subject to an Out of Court Disposal or Post- Court Order within last 12 months OR Offended three times or more in the previous 12 months

Referrer's main concerns

Chances Referral Criteria

Low school attender/ attending on a part-time timetable/ in alternative provision/ excluded from school (therefore also at risk of NEET). Not in Education, Employment or Training (NEET) or At Risk of NEET Are subject to an Out of Court Disposal or Post- Court Order within last 12 months OR Offended three times or more in the previous 12 months

Magdalen Road Gym LiFT Youth Referral Form - Monday 2pm - 3pm

LiFT Youth

Identity

Demographic

Address

Contact

Doorstep Sport Impact Programme - Community Safety

Lifestyle

TV VRU Referral Criteria

Refer Information

Consent

Education Provider Information

Additional Assessment Information

Brief History

Health

Referral Information