Refer a student - Lyward Colley Workshops

Young Person’s Details

Forename

Preferred Name

Application made by

Date of birth

Year group as of September 2025

pronouns

Gender

Free school meals

Yes

Customer contact Details

Application Made By:

School/Service

Contact Address Line 1

Contact Address Line 2

Contact Address Line 3

Locality

Town/City

County

Postcode

Contact Telephone

Contact Email Address

Invoice to email address

Parent/Carer/Emergency Contact Details

First contact name

Second contact name

First contact relationship

Second contact relationship

First contact home telephone number

Second contact home telephone number

First contact mobile number

Second contact mobile number

First contact email address

Second contact email address

First contact address

Second contact address

How will student get to and from Lyward Colley?

Safeguarding Information

CIC

Yes

CAF/TAC/CIN/CP Plan

If yes, name and contact details of Co-ordinator/Social Worker:

Senior Designated Safeguarding Lead

Medical Details

Surgery

Doctor's Name

Surgery Telephone Number

Known Medical Issues/allergies

Does the child have a history of substance misuse?

SEN Information

Does the child have any SEN requirements

Yes

SEN Support

EHCP

Description of Need:

Does the young person attend other provisions

Yes

If yes please state where and if known what their current timetable is:

Referral Details

What are the reasons for referral?

What are the young person’s strengths?

What interests the young person?

In what areas has young person been struggling?

How does this present itself? (attitudes, behaviour, attendance, exclusion details)

What interventions/support have been tried? How have these helped?

Are there any know reasons/triggers?

What are the young person’s personal goals?

What are the Parent's/Guardian’s goals for them?

What are the referrer’s Goals for the young person?

Acknowledgments

I acknowledge that the information within this referral is complete and accurate at the time of writing and that I have the consent of the Young Person and appropriate Parents/Carers to share this information.

Name

position

Date

We sometimes would like take photos and/or videos of students during workshop activities. Please indicate if and how you consent for the way in which we can use photos of the child:

Photos/videos can be shared, published, including on Lyward Colley related social media and used for marketing

Photos/videos can be used within Lyward Colley Workshop spaces only but not for marketing purposes

Do not take photos/videos of this child

Please specify which workshop would most suit this child best

Whilst we attempt wherever possible to accommodate the child in their first workshop of interest, session availability might mean alternatives may need to be considered. This will be discussed directly between the referrer and the workshop mentor before any sessions begin