Kids on Track Sports Programme Referral
Referral Information:
• Please complete all sections and relevant information
• If you don’t know, please say so

The information on this form will be used to keep the children at Kids on Track safe. We will never share your details with a third party unless required to do so by law.

All data is stored in accordance with the Data Protection Act 1998.

For further information about how the information is used, how we maintain the security of your information, and your rights to access the information please contact a member of the Kids on Track team.

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Your Contact Details
Your name *
Your role *
Your email address *
Your telephone number *
Child's Contact Details
Childs name *
Child's School
Child's date of birth
MM
/
DD
/
YYYY
Name of  parent / guardian
Telephone number of parent / guardian
Sports club the child wishes to attend
Reason for referral
Are the parents able to provide transport to and from the club and / or matches.
Clear selection
Do you think this child / young person will show commitment to attending the club and why.
Background
The following helps us to understand a child’s background in order to support the child effectively and deal with any issues that might arise.  The referral will be discussed in much more detail during a face to face meeting with the family support worker.  What you write here is a starting point for the conversation.  
 Learning
Wellbeing
Social and Emotional Skills
Pupil Premium Status
Does this child require 1:1 adult attention
Clear selection
Is this child on a child protection or child in need plan?
Clear selection
If the answer is yes to the above please could you provide the name and contact of the child's social worker (if not named in the above referral.)
Is this child at immediate risk?  Does anyone want to hurt or abduct this child?
Thank you for taking the time to fill out this form
Data Protection
The information on this form will be used to keep the children safe whilst taking part in Kids on Track activities. We will never share your details with a third party unless required to do so by law.All data is stored in accordance with the Data Protection Act 1998.For further information about how the information is used, how we maintain the security of your information, and your rights to access the information please contact a member of the Kids on Track team.
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