1. Referrer's and Child's Details:

Referrer's name

Referrer's contact number

Referrer's email address

Referrer's/organisation's address

Referrer's relationship to child

Childs/ young person's name:

Child/ young person's date of birth

Child's/ young person's address

2.Parents/Carers details (if not the person making the referral)

Parent/Carer name:

Parent/Carer Contact number

Parent/carer Address

3. Named contact and Telephone number in case of emergency:

4. Reasons for referral (Select top 3)

1.

2.

3.

5. Additional Information

Does the child or young person have any allergies, including food allergies or pre-existing medical conditions that we should be aware of - please detail below;

Risk Assessment - Is there anything specific that we should be aware of that could present a risk to this child/young person or would they present a risk to others working in a group or 1:1 session;

Please state any other information that you think would be relevant;

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During participation in sessions photographs may be taken and we would like your permission to use any photographs in the following ways: in CYP Gardening Project publications e.g. Annual report, website, promotional material e.g. leaflets and at events to promote the work of the project and our social media accounts e.g. Facebook, Twitter and Instagram.  We would also like to build an album for the children & young people to keep when they finish attending.

6. Photograph consent

7. Referrer's Signature

Thanks for submitting.

You will be responded to within 48 hours