Views External

Identity

Young Person Forename

Young Person Surname

Also Known As

Young person's pronouns

Date of Birth

Demographic

Gender

Ethnicity

Disability

Religion

Sexuality

Do you receive any additional support for you and your family such as Free School Meals, Universal Credit, Housing Benefit, Working Tax Credit etc

Address

Young Person's Address 1

Young Person's Address 2

Town

County

Post Code

Contact

Young Person's Telephone

Young Person's Mobile

Young Person's Email

Parent/Guardian Information

Parent/guardian full name

Parent/guardian mobile number

Parent/guardian address (if different to young person)

Parent/guardian email address

Relationship to young person:

Alternative Emergency Contact Information

Full name

Mobile number

Relationship to young person

Medical Information

Does the young person have any medical conditions or allergies?

Does the young person have any diagnosed or undiagnosed disabilities or learning difficulties?

Is there any additional information you would like to share to help us to support the young person? Any information shared will remain confidential

Is the young person working with any other agencies, e.g., social services, support services, etc.?

Declaration

I am happy for the young person to be in photos, videos, or audio recordings and for these materials to be used by the charity, and our partners. For example, shared via social media, newsletters, etc.

I am for the young person to travel in a car with a TRAIN member of the youth work team

** ONLY APPLIES TO THOSE 12 AND UNDER ** - I am happy for the young person to leave by themselves at the end of the session. For more information please message Georgie on 07394095986

** ONLY APPLIES TO THOSE ENGAGING IN THE MENTORING PROGRAMME** - I am happy for the young person to engage in the Mentoring Programme. This programme will support young people by covering a range of topics.

Young Person Referral