The Wildly Different Programme 2023
First Event: Taster Day Saturday 25th March 11am - 4pm
Application Form
In completing this form you are applying for a young person (YP) (12 - 16) to take part in The Wildly Different Programme from April to August 2023. Building supportive relationships for YP with staff and peers, having fun, new experiences and exploring challenges are all part of the opportunity. The Wildly Different Programme includes day trips in and out of the city, a residential, 'progression' contact to support engagement with other opportunities and an end of programme celebration event. Parent/carer/support worker involvement is key to success for YP. We offer participation in parts of the programme for the whole family and support organisations alongside the YP. Imayla's work is delivered to local and national government guidelines on Covid 19. Spaces are limited to 12, so tell us as much as you can to help aid the allocation of spaces. Priority is given to YP from East Central Bristol.
Equalities Information
Please complete the equalities information form
HERE
Have you completed the equalities Information form?
*
Yes
Section 1. The young person you are applying for:
Young Person's Name
*
First Name
Last Name
Young Person's Date of Birth
*
Young Person's Address
*
Street Address
Street Address Line 2
City
County
Postal Code
What school does the Young Person attend?
*
Section 2a. Referrer:
Your Name
*
First Name
Last Name
What organisation are you from?
*
Leave this blank if it's not applicable to you
What is your relationship to the young person or child?
*
e.g: social worker / youth worker / parent / carer
Your Address
*
Street Address
Street Address Line 2
City
County
Postal Code
Your Phone Number
*
Please enter a valid phone number.
Your Email Address
*
example@example.com
Section 2b. Parent/Carer:
If the same as above leave blank
Parent/Carer Name
First Name
Last Name
Parent/Carer Address
Street Address
Street Address Line 2
City
County
Postal Code
Parent/Carer Email Address
example@example.com
Parent/Carer Contact Number
*
Please enter a valid phone number.
Section 3. You're half way through! Tell us about the young person:
We will be using this section to make decisions on allocating places on the programme so please give us as much information as you can and please include the views of the YP
How do you feel the young person would benefit from participation in The Wildly Different Programme?
*
Tell us what hobbies, interests and aspirations the young person has?
*
Section 4. Please tell us about any organisations, agencies or groups currently supporting the young person:
Please list the relevant organisation name, contact person and contact details including email address and phone number.
*
Section 5. Cost:
This is a free programme. Donations towards enhancing activities are welcome.
I would like to donate - we will follow this up with you
Is there any other information you would like to tell us to support the application?
*
Thank you for completing this application!
We will be in touch following the allocation meeting to let you know if your application has been successful. For further discussion about this application please call: 07585 028609 or email: admin@imayla.co.uk. For more detail about Imayla and The Wildly Different Programme go to: www.imayla.com
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