PROGRAMMES IN BIRMINGHAM

THE ULTIMATE SPORTS-THEMED YOUTH PROGRAMMES

PROGRAMME / ACTIVITIES / BENEFITS
SPORT 4 LIFE TEENS
>SPORTS-THEMED EDUCATIONAL PROGRAMME FOR 12-16 YR OLDS (EVENINGS) / >FOOTBALL & SPORTS SESSIONS
>FUN EDUCATIONAL WORKSHOPS
>SPORTS TRAINING COURSES / >IMPROVE BEHAVIOUR
>LEARN LIFE SKILLS
>GAIN QUALIFICATIONS
SPORT 4 LIFE NEETS
>SPORTS-THEMED EMPLOYABILITY PROGRAMME FOR 16-25 YR OLD NEETS (DAYTIME) / >EMPLOYABILITY TRAINING & SUPPORT
>TRAINING COURSES
>SPORTS VOLUNTEERING / >HELP FINDING A JOB
>GAIN QUALIFICATIONS
>IMPROVE EMPLOYMENT PROSPECTS
REFERRALS
>ACCEPTING REFERRALS OF CHILDREN & YOUNG PEOPLE NOW
>TO BE ELIGIBLE MUST HAVE BEHAVIOUR / EDUCATIONAL / HOME PROBLEMS
>SIMPLY COMPLETE THE FORM OVERLEAF

REFERRAL FORM

DETAILS OF YOUNG PERSON
Full Name / Telephone/Mobile Number
Date of Birth / Email Address
Postal Address & Post Code
Emergency Contact name & Relationship / Emergency Contact number:
Gender / Male Female / Do you have a disability? / Yes No
Ethnicity / White-British
Any other White background
Asian – Pakistani
Any other Asian background
Any other Black background / White – Irish
Mixed ethnic background
Asian – Bangladeshi
Black – African
Arab / White – Gypsy/ Irish Traveller
Asian – Indian
Asian – Chinese
Black – Caribbean
Any other ethnic group
Religion / No religion / Christian / Buddhist
Hindu / Jewish / Muslim
Sikh / Other religion
How did you find out about Sport 4 Life and the programme? / e.g. Job Centre, Princes Trust, Friends, Key Worker
Details of any medical conditions – including educational/special needs/learning difficulties
PERSON REFERRING THE YOUNG PERSON
A partner organisation referring a young person aged under 18
A parent/guardian referring a young person aged under 18
A young person aged 18+ self-referring themselves
Full Name / Organisation (if applicable)
Telephone/Mobile Number / Email Address
Postal Address
Which Sport 4 Life Project are you referring the young person to?
IMPORTANT ELIGIBILITY INFORMATION
The funding that Sport 4 Life receive from our generous partner organisations only allows us to work with young people who face specific BARRIERS / CHALLENGES in their lives. Therefore in order to ensure that young people are eligible for a 100% free place on our programmes they must hit one or more of our 6 eligibility criteria (see below for more details).
REASON FOR REFERRAL (tick all that apply)
BEHAVIOURAL
Temporarily excluded from school
Permanently excluded from school
Involved in behaviour management at school / CRIMINAL RECORD
Has a criminal record
Known to police (but no record)
Involved in anti-social behaviour / SUBSTANCE MIS-USE
Marijuana use
Other drug use
Alcohol
MENTAL HEALTH
Confidence issues
Anger issues
Diagnosed with a mental health issue / DISADVANTAGED
Low income/benefits
Lives in a deprived neighbourhood
Lives in care / EDUCATION/ EMPLOYMENT
Not in education, employment or training
Underachieving at school
Low attendance at school
IF YOU HAVE TICKED ANY OF THE ABOVE PLEASE COMPLETE THE QUESTIONS OVERLEAF IN AS MUCH DETAIL AS POSSIBLE
Young Person Lifestyle (tick all that apply)
Has drunk AlcoholIs a teenage parent
Has smoked cigarettesHangs out on the street with friends
BACKGROUND DETAILS ABOUT THE YOUNG PERSON
Education Details / Is the young person permanently excluded from school? / Yes No
How many days has the young person been excluded over the last 2 years?
What is/has been the attendance rate of the young person (%)?
Rating level of educational support need / Low Med High
Is the young person predicted to or has achieved 5 A*-C GCSEs / Yes No
Please give details of any statement of educational needs/special needs/learning difficulties
Which of the following applies to the young person (please tick all that apply)?
In mainstream education In alternative education provision Not in education
At secondary school At college At university On a training scheme (e.g, apprenticeship)
Name of educational institution/training provider
Contact person/teacher at educational institution
Telephone number of contact person/teacher
Employment Status / Which of the following applies to the young person?
Not working at all Working 16 hours or less per week Working more than 16 hours per week
How long has the young person been unemployed for?
Less than 3 months / 3-6 months / 6-12 months / 1 Year+
Mental Health Needs / Please give details if the young person has any mental health needs
Family / What is the young person’s housing and family situation?
Please give details of any Social Services involvement with the young person
Addiction Issues / Please give details if the young person has issues with drug or alcohol use
Disability / Please give details if the young person has a disability
BACKGROUND DETAILS ABOUT THE YOUNG PERSON (continued)
Offending Behaviour / Has the young person ever been in trouble with the police? / Yes No
Please provide any details:
Has the young person got a criminal record? / Yes No
Details of any convictions, cautions, warnings or reprimands
Were any of the convictions for:
Serious Violence Arson Sexual Offences Offences against children
Date of last conviction
Length of sentence
Number of prison sentences
Is there a risk of the young person re-offending? / Yes No
If yes, please rate the level of risk / Low Med High
Is/has the young person been at a Young Offender Institute? / Yes No
Name of institute
Contact person/telephone number of institute
Other Information / Does the young person have any other workers allocated to them from different agencies? Give details.
Is there anything else we should know? (e.g. membership of gang, anger management issues, etc)
Any known triggers for challenging behaviour
Any strategies you have found successful in managing challenging behaviour
CONSENT DECLARATION – To be completed by parents/ guardian only (unless participant is over 18 years)
  • GENERAL CONSENT:
I give consent for my child/children/myself to: (i) participate fully in all of the activities provided by Sport 4 Life, inclusive of but not limited to sporting activities, educational workshops (including drugs, alcohol, and sexual health workshops), training courses, qualifications, volunteering opportunities, and special trips and excursions, (ii) be transported to external locations by foot, car, train or coach/minibus, as necessary for the project, (iii) return home unaccompanied from activities, and (iv) be contacted by Sport 4 Life by text, email, or social media. I confirm I am happy for personal data, comments and personal stories from my child/children/myself to be stored and processed by Sport 4 Life and used for marketing purposes, in line with the Data Protection Act. I confirm I will report any changes to our/my address or contact numbers to Sport 4 Life immediately.
  • MEDICAL CONSENT:
I confirm that my child/children/myself are in good health and I consider him/her/them/myself capable of taking part in all activities. I have completed the medical details information above fully and accurately, and consent that in the event of any illness/accident, any necessary medical, surgical, dental or first aid treatment can be administered to my child/myself by trained members of staff or medical authorities, which may include the use of anaesthetic. I consent for my child/children/myself to be transported to hospital in the case of serious injuries. I understand that while Sport 4 Life’s staff will take every precaution to ensure that accidents do not happen, they cannot necessarily be held responsible for any loss, damage or injury suffered by my child/children/myself. I will inform the project staff of any important changes to my child’s/children’s/my health and medication.
  • PHOTOGRAPHIC CONSENT:
I understand that to help promote and evaluate the activities, there may be video filming and photography at some sessions which may be used for internal and external purposes e.g. leaflets, newsletters, reports or on social media and official websites. I give permission for my child/children/myself to be filmed or photographed during all activities as described
Full Name / Telephone/ Mobile
Signature / Date

PLEASE RETURN A COPY OF THIS TO: or by post/person to Sport 4 Life UK, Suite 2B, Morcom House, Ledsam Street, Ladywood, Birmingham B16 8DN