Y-Act Registration Form
Personal Information
Young Person's Full Name
First Name
Last Name
Young Person's Date of Birth
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Day
-
Month
Year
Date
Home Address
Street Address
Street Address Line 2
City
Region
Post Code
Current Address (If different from Home Address)
Street Address
Street Address Line 2
City
Region
Post Code
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Contact and Communication
Parent/Guardian/Carer's Full Name
First Name
Last Name
Relationship to Young Person
Parent/Guardian/Carer's Contact Telephone Number
Parent/Guardian/Carer's Email Address
example@example.com
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Emergency Contact Details
Emergency Contact 1
Name
First Name
Last Name
Relationship to Young Person
Contact Telephone Number
Emergency Contact Details
Emergency Contact 2
Name
First Name
Last Name
Relationship to Young Person
Contact Telephone Number
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Additional Support Needs
Does the young person have any additional support needs? (e.g. English as their second language, hearing impairment, ADHD, ASN, Autism etc.)
Does the young person have any medical conditions or special requirements we should be aware of? (Please provide details)
Wellbeing
Which of the following areas do you think the young person would benefit from support with? (tick all that apply)
Building Confidence
Improving Mood
Feeling Less Lonely
Making New Friends
Developing Social Skills
Consent
Consent for use of images and videos
We may use images and videos of the young person for case studies, social media, and marketing purposes. Please check the box to confirm you consent to this:
Yes, I consent
No, I do not consent
Education Information
School attended by the young person
Named contact for the school (teacher / headteacher name)
First Name
Last Name
Named contact's telephone number
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Additional Support
Are there any other agencies or professionals currently supporting the young person or family?
Yes
No
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Name of agency / professional (eg. CAMHS, Social Work, Educational Psychologist, etc.)
Type of support provided (eg. 1:1, group sessions, spends school days at Wellbeing Hub etc.)
Frequency of involvement (eg. daily, weekly, monthly, as needed)
Any progress you have noted from their support?
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Please note: Submitting this form does not guarantee a place at Y-Act, all applications are subject to availability and meeting criteria. A member of the team will contact you to confirm a place has been allocated.
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