Chessbrook ESC - Alternative Provision 2020/21
This is our online form for schools to refer their students to our alternative provision courses. Referrals for TUTE should be made using our online TUTE referral form.

PLEASE NOTE: we will also need the signed copy of the permissions form with all signatures before we can accept any referral. Please submit this by email to: Email it to apreferrals@chessbrook.herts.sch.uk 

You must have permission and authorisation from your Alternative Provision budget holder prior to submitting a referral.  Referrals must be submitted by Friday, 12pm to be accepted for the following week.
Sign in to Google to save your progress. Learn more
School/Organisation *
Full Name of Student *
Current Year Group *
Date of Birth *
Gender *
Required
Unique Pupil Number (UPN) *
Unique Learner Number (ULN) *
Home Address *
Who does the student live with? *
Does the student have any medical needs *
Do they take regular medication during the school day? *
Does this student have a health plan/risk assessment based on their medical needs? *
If yes to the above, Please list their medical needs/medication they take
If the student has a health plan based on their medical needs, please provide us with the details of their GP / Registered Practice in case on an emergency
Contact 1 - Full Name *
Contact 1 - Relationship *
Contact 1 - Telephone Number *
Contact 2 - Full Name *
Contact 2 - Relationship *
Contact 2 - Telephone Number *
Does student have additional needs? *
Does the student have an EHCP? *
Please note that if this student has an EHCP, we will require a copy of this to be sent with the parental consent form to ensure we are meeting their needs
I can confirm that I will be sending a copy of the students EHCP with the parental consent form *
Required
Please list or give an overview of their additional needs
Additional information *
Yes
No
Pupil Premium
Free School Meals
Risk Assessment in place (if yes please fill in box below)
Safeguarding concerns (if yes please fill in box below)
CLA
CIN
Any other information that will help us support your student (i.e. strengths, interests, behaviours, triggers) *
Academic Skills *
Above age related
Age related
Below age related
Reading
Writing
Maths
Any other useful information about academic ability? *
Key Stage *
Areas of learning the student is interested in? - For TUTE please complete the TUTE referral form - https://forms.gle/S8ZMaUme2tYYQWFw8 *
Required
Date you would like this to start *
Date you would like this to finish *
Any preference over days/times? (Depending on availability)
Name of person completing this form *
Your email address *
Would you like to receive attendance notifications? *
Required
Contact name of person responsible for the monitoring of this students attendance *
Attendance email *
Attendance contact number *
*
Required
I confirm that we wish to enrol the above student on Alternative Provision and that they remain our responsibility as they remain on our roll (Main) - Please note that the student will appear on Chessbrook's roll as 'Guest Pupil' *
Required
COVID-19 | We can confirm that we have carried out an individual risk assessment around COVID-19 based on the students individual needs. (due to the fact they will mix with other young people outside of our school)
We confirm that we will include the student within our COVID-19 testing programme and retain responsibility for this
I confirm that we have consulted with parents/student who have agreed to this referral *
Required
I can confirm that I have the budget authorisation to submit this referral *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chessbrook Education Support Centre. Report Abuse
Google Forms