Appleseed Referral Form -

Please print off to fill in and send to us,

or complete electronically and email

Young Person’s details:

Name:______Date of Birth:______Address:______

Tel number______Mobile number______

Email address______

Emergency contactname:______

Tel number______Mobile number______

Secondary School ______

Referral agent/ parents/ carer details:

Name:______

Relationship to client:______

Organisation______

Address:______

Tel number______Mobile number______

Email address______

GP information:

GP Name:______Tel number______

GP Surgery address: ______

______

Further information: Which day would you like to attend?Please circle, tick or highlight

13 to 16 year olds:Tues 13th Feb / Thurs 15th Feb/ Tues 3rdApril/ Thurs 5th April / Tues 29th May / Thurs 31st May /

Tues 31st July / Thurs 2nd Aug / Tues 14th Aug / Thurs 16th Aug / Tues 23rd Oct / Thurs 25th Oct

17 to 19 year olds: Tues 10th April / Thurs 12th April / Tues 21st August / Thurs 23rd August

What do you hope to gain through visiting Appleseed?______

______

What medication do you take? ______

Will you be carrying medication? ______

Are there any risk factors we need to be aware of? ______

______

I am willing for my child to take part in Appleseed Taster Days, and having read all the information provided, I agree to his/her taking part in the activities involved

I fully understand that, while Appleseed staff in charge of the group will take all reasonable care of the young people, they cannot necessarily be held liable in respect of loss or damage to property or injury suffered by my child arising out of the taster day, unless such loss, damage or injury results from the negligence of Appleseed, its staff or official volunteers.

I agree to my child receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

The information on this form will be stored on a database and will be used for the administration and delivery of activities being organised by MTM Youth Services CIC to monitor statistical information for the visit and for no other purpose, in accordance with the Data Protection Act (1988). All personal information will be held in the strictest confidence. It will not be made available to any third party other than those directly involved in the organisation and delivery of visit activities.

Photography

During the course of Appleseed taster days, there may be opportunities to publicise some of the activities that the young people are involved in. This will involve photographing young people for use in the local media; we welcome these opportunities and hope that you do too. There may also be occasions when we arrange photography for our own purposes, such as displays, our website and publicity brochures. Photography will only take place with the permissions granted by the signature of this form. Home addresses will never be given out.

Having read the statement above, do you give your consent for photographs or other images to be taken and used? (please tick the appropriate box) / YES, I give my consent for pictures to be taken and used
NO, I do not give my consent for pictures to be taken and used

Signature of referrer: ______Date:______

Please send the completed form to our registered office or email to

Appleseed Referrals, Sam Mason, 1 Rambler Cottage, The Street, Botesdale, Diss. IP22 1BZ

Thank you! We look forward to meeting you soon