Referral!

Name of child

First Name

Last Name

Date of birth of child

MM

DD

YYYY

Name of guardian

First Name

Last Name

Preferred contact for guardian (telephone, or email)

Postcode of child

Contact details for professional

Please provide an email or telephone contact to confirm the family's needs

What identified need do the family have which makes them eligible for support?

Please provide a description of the family's needs (i.e. safeguarding) which makes them eligible for funding. See our eligibility page for more info.

What activity is the child interested in and what days?

Please provide details of the activity your child is interested in, & the day/times you would want the child to be in an activity.

Does the child have a diagnosed developmental, physical or mental health need, or require 1-2-1 clubs?

Yes

No

If yes to the above, please provide the name of a club that has been identified as suitable for the child

Due to the additional difficulty in finding a club locally for a child that requires 1-2-1, or has a diagnosed mental/physical health, we now ask that specific clubs are provided for these children in advance by the referrer.

Does the child attend any club type activities outside of the home at present?

Yes

No

Does the child already receive funding for activities outside of the home?

Yes

No

Financial eligibility

If the referred household earn more than £40,000 before tax each year, we are regrettably unable to help. To see if we can help you, we will possibly look at your income, benefits, savings and assets. We will ask for proof of your income such as your payslips. If we suspect you are of higher income, and you do not wish to give us this information, we may have to reject you. Please confirm the family earn less than £40,000 pre-tax.

They earn less

They earn more

Have you had consent from the family for this referral? If no, why not?

Please read our eligibility criteria prior to making a referral. We receive a significant number of referrals daily, many of which do not match the required criteria stated on our eligibility page. If a referral is received which does not match our criteria, the referral will be rejected, and a new referral will need to be made.

Referral!

Active Respite