/ Multi Sports and Performing Arts Programme
SCHOOLS OPEN FOR EASTER 2015
SCHOOL/AGENCY REFERRALS ONLY
Priority Referral Bookings
From 9th March 9.30am to 13th March 2015 5.30pm only
General Bookings open 9th March to 17th April 2015 /

1. Child/Young Person (PLEASE COMPLETE FORM FULLY AS INCOMPLETE FORMS MAY BE RETURNED)

Name of Child/Young Person (full name)
Date Of Birth / Gender / Male Female
Disability Yes No If yes please state: / Photographs (permission to take photos for promotional purposes for LBWF only) Yes No
Medical (Please indicate any health issues, injuries, allergies, special needs or medical conditions) / Which school does the child/young person attend?
Other Relevant Information: (please complete fully)
Is there any other information that we need to know? i.e. Behavioural issues, nature of physical and/or learning disability
Please also include legal status of child/YP such as LAC or subject to any court orders.
Please ensure that you inform us of any additional support that the child/YP may need in order to participate in these activities (please provide clear details of the nature of the difficulty and the level of support required). Use an additional sheet if required and send with application.
Full Name of Parent/Carer / Are you Over 18 years of age? Yes No
Address / Postcode
Emergency Contact 1 - Full Name: / Relationship to Child: / Home Tel:
Work Tel:
Mobile:
Email:
Emergency Contact2 - Full Name: / Relationship to Child / Home Tel:
Work Tel:
Mobile:
Email:

2. Parent/Carer details

3. Referrer’s details

Name of Referrer / Job Title
Name of Organisation / Email
Contact Telephone No. / Mobile
Are you contactable during the Easter? If not, please provide alternative contact / Yes No If there is an allocated social worker or another organisation that is working with the family please ensure you include the contact details of someone who is contactable during the period of the booking.

4. Ethnicity (please place a tick next to the correct ethnicity)

White British / Black or Black British / Any other dual or multiple heritage
White Irish / African / Bangladeshi
Any other White background / Caribbean / Indian
Albanian / Any other Black background / Pakistani
Greek/ Greek Cypriot / White and Asian / Any other Asian background
Kosovan / White and Black African / Chinese
Turkish/ Turkish Cypriot / White and Black Caribbean / Gypsy/Roma
Any other ethnic group

5. Session Booking (please state clearlywhich dates you require against the activity/venue).

Activity / Provider / Venue / Date & Time / Booking Dates
Multi Sports / Tottenham Hotspur Foundation / Walthamstow School For Girls, Church Hill, Walthamstow E17 9RZ / Tuesday 7th April to Friday 17th April
9.30am to 3.30pm
Performing Arts / X7eaven / Walthamstow School For Girls, Church Hill, Walthamstow E17 9RZ / Tuesday 7th April to Friday 17th April
9.30am to 3.30pm
Multi Sports / Leyton Orient / The Score Centre
100 Oliver Road, Leyton, E10 5JY / Tuesday 7th April to Friday 17th April
9.30am to 3.30pm
Disability Multi Sports / Tottenham Hotspur Foundation / Peter May Sports Centre
135 Wadham Road
Walthamstow
E17 4HR / Tuesday 7th April to Friday 17th April 10.30am to 3.30pm

6. Reason for referral(please tick)

Category / Category
Common Assessment Framework (CAF) / Risk of Gang Involvement
Child in Care / Families just below social care threshold
Difficulties in Social Engagement / Welfare Concerns
Low income families / Child/young person with disability
Known to Early Help Service / Young Carers
Known to Social Services / Teenage parents
Other (Please specify):

7. Payment Method(please tick one, Tottenham Hotspur Foundation will make contact with either party to collect payment)

Total No. of days / Total Cost:
Payment by School/Organisation / Payment by parent/carer
Income based Benefits Criteria – Name National Insurance No. Date of Birth
Please supply proof of benefit: Letter dated within last 3 months stating type of benefit

I give permission in case of an emergency for my child/ren to be taken to hospital

by ambulance: Yes No

I give permission for my child to walk home alone (Over 8’s only): Yes No

Parent /Carer Signature: ………………………………………………………………..Date ……………......

Referrers Signature: ……………………………………………………………………. Date ……………………....

Please ensure that you complete a separate form for each child/young person and return to Central Administrator at Tottenham Hotspur Foundation:

Post: Tottenham Hotspur Foundation, Bill Nicholson Way, 748 High Road, London N17 0AP

Email:

Tel: 020 8365 5138 (Enquiries only Monday-Friday 9:30am-5:30pm)

Fax: 020 8365 5053

How did you find out about these activities? Word of mouth Flyers/Leaflets Council website

Free newspaper School Other (please specify) …………………………………………………..

There are lots of other activities going on over the Easter holidays, for more

Information visit: