Y-Act Registration Form 2025/26
Personal Information
Young Persons Full Name
First Name
Last Name
Young Persons Date of Birth
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Address (if different from home address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Contact & Communication
Parent/Guardian/Carer's Full Name
First Name
Last Name
Relationship to Young Person
Parent/Guardian/Carer's Telephone Number
Parent/Guardian/Carers Email Address
example@example.com
Back
Next
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
Back
Next
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
Developing Social Skills
Stronger relationships with peers
Increased creativity
Improved communication 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 telephone number or email address
Back
Next
Additional Support
Are there any other agencies or professionals currently supporting the young person or family?
Yes
No
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?
Back
Next
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.
Submit
Should be Empty: