African Community School
Pupil Referral Form /
Section 1: Referring Agency/School details
Name of referrer
Name of organisation/School:
Address:
Tel number/email address:
How long and in what capacity have you known the young person/child?

Please tick vo confirm that the young person/child is a Hackney resident

/ o
Section 2: Children and Young Person’s details
Name of child or young person/
First Name / Last Name:
Name of School
Date of Birth / Age
Name of parent/career:
Address: / Post code
Telephone Number
Ethnic group:
White
o British
o Irish
o Any other White Background
(Please write in)……………………………………...
Mixed
o White & Black Caribbean
o White & Black African
o White & Asian
o Any other Mixed Background
(please write in)………………………………………
Asian or Asian British
o Indian
o Pakistani
o Bangladeshi
o Any other Asian Background
(please write in)………………………………………
Language spoken by young person/child / Black or Black British
o Caribbean
o African
o Any other Black Background
(Please write in) ………………………….………….
Chinese
o Chinese
Other Ethnic Group
o Any other Ethnic Background
(Please write in) …………………………………….
Gender:
o Male
o Female
Language spoken by family
Section 3: Individual Needs
Does the young person/child have any SEN? Yes No
If ‘Yes’, please give brief details
Year group:
Section 4: Additional Information
Are any other agencies involved? Yes No
If ‘Yes’ please provide agency details
Is there any medical information we should be aware of?
If ‘Yes’ please give details Yes No
Declaration
Signed…………………………………………………………………………Date…………………………
We require parental consent before begin working with a young person. We also require consent from the young person to ensure that they want to engage in the project. Please either gain a signature from the parent/guardian and young person or if you have gained verbal agreement, please tick the box below.
Signature of parent/guardian (if under 16)…………………………………………..Date ………………….
Signature of young person …………………………………………………………… Date………………..
OR
Verbal agreement from parent/career is acceptable (please tick if verbal consent gained)
Date obtained ………………
Verbal agreement from young person to engage in the project.
Date obtained………………

The Pupil Attainment Report assists us to measure the pupil’s current attainment level at the start of involvement. This will also assist us to devise an action plan and measure our intervention Please complete the Pupil Attainment Report

Name of child or young person/
First Name
Last Name

Please provide achievement data for the current academic year: -

Attendance (%)
Number of detentions
Number of exclusions
KS English
KS Maths
KS Science
Behaviour rating
Effort rating
Comments
Date completed
Name
Position
Signature

Please return this form to Kome Owuasu Development Officer, African Community School, c/o Princess May Primary School, Princess May Road, N16 8DF. If you have any questions please call 0207 249 5748, 07863234832 or email .

This information will be treated as confidential and will only be seen by the Project

Co-ordinator. The parent of the children has the right to access this information at any time on request.

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