Step Up Screening Consent Form

To Be Completed by Parent/Guardian

For your young person to be considered for inclusion in the YDP this form must be fully completed & returned to: Cabra Step Up Project

Screening Consent
Your son/daughter has been referred to Step Up (Cabra for youth Clg) by First Name Last Name The Project will assess your young person’s needs to ensure the YDP is the most suitable service for them at this time. Step Up works with other agencies such as the Gardaí, schools etc. to provide the best possible service to young people and their families. This may involve sharing information with them. If Step Up is not in a position to meet your son/daughter's needs we may recommend a more suitable support for them.
Young Person's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address of Young person*

Street Address

Street Address Line 2

City

Eircode / Postcode
YesNo
Parent / Guardian's Address*

Street Address

Street Address Line 2

City

Eircode / Postcode
Mobile Number of Parent / Guardian
Please enter a valid phone number.Format: 000 000 0000.
Consent

I understand that my son/daughters needs will be assessed to help decide if the YDP could be of benefit to them. I understand that the project works with other agencies to ensure that my young person’s needs are met in the best possible way. This may involve sharing relevant information. I agree to this. I also understand that this information will be kept in accordance with the Data Protection Act 1998 &2003.
Full Name of Parent / Guardian*
Relationship to Young Person*
e.g. mother, father, grandparent etc
Parent / Guardian Signature *
Date*

DayMonthYear
This project is co-funded by the Government of Ireland and the European Union

For more information see www.eufunds.ie
Should be Empty:

To Be Completed by Parent/Guardian

Screening Consent

Consent

This project is co-funded by the Government of Ireland and the European Union