Sherlock Pathways Application Form

Sherlock Pathways Application Form
Referring School Details
School making this referral
School address, contact number and email
Will you be funding this provision?
If no, please state who will be funding
Name of person making this referral

First NameMiddle NameLast Name
Main school contact name (if different)

First NameMiddle NameLast Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address (main school contact)
example@example.com
School DSL name

First NameMiddle NameLast Name
DSL contact number
Please enter a valid phone number.Format: (000) 000-0000.
DSL email address
example@example.com
School DDSL name

First NameMiddle NameLast Name
DDSL contact number
Please enter a valid phone number.Format: (000) 000-0000.
DDSL email address
example@example.com
Consent & Roll Status
Has parental/carer consent been obtained for this referral?
Was this consent obtained verbally or in writing?
Is the student aware of this referral being made?
Is the student on roll at your school?
Will the student remain on roll at your school for the duration of this alternative provision programme?
Is this student currently attending school?
Does this student have a full-time timetable at school?
If not, how many hours is the student timetabled?
Student Details
Student Name

First NameMiddle NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Year Group
Attendance this year
Gender

Other
Home Address
ULN
Ethnicity
Child Looked After
Which authority (Child Looked After)
FSM
Allergies / Dietary Requirements
Does this student access any other Alternative Provision?
If so, where and for how many hours/days per week? Are the other provider/s OFSTED registered?
Will your school remain the substantive education provider throughout this academic year, if you proceed with this referral?
Is this student entitled to access arrangements?
If so, what are these access arrangements?
Current working level - English
Current working level - Maths
Reading Age
Emergency Contacts
Name of Emergency Contact 1

First NameMiddle NameLast Name
Emergency Contact 1 - Direct Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 1 - Direct Email
example@example.com
Emergency Contact 1 - Relationship to Student
Name of Emergency Contact 2

First NameMiddle NameLast Name
Emergency Contact 2 - Direct Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 - Direct Email
example@example.com
Emergency Contact 2 - Relationship to Student
Safeguarding & Support
Does this student have Social Care involvement?
Does the student have a social worker?
If yes, please provide social worker name and contact details
Does this student have any relevant medical information?
If yes, please provide medical information details
Does this student take any medication?
Medical - medication details
Please outline any SEN support that this student receives in school (including successful strategies)
Does this student have SEND status?
If there is an EHCP, has this been shared with this referral?
Please provide details of any known triggers for this student
Has a student Risk Assessment been provided to support this referral?
Has this Risk Assessment been completed or reviewed within the last month?
Are there any active concerns around this student and involvement in the following activities
If yes, outline these concerns in the student Risk Assessment
Is this student supported by any other agencies?
If yes, please provide other agency service details
Travel & Logistics
Has a travel Risk Assessment been completed by the referring school?
Have barriers been considered prior to making this referral? If any, what barriers may arise?
Have travel arrangements been discussed and confirmed with the student and parents/carers?
Provision Details
Training Provider(s) this student is being referred to
Course applying for
Day(s) applying for
Is this referral for full days, half days or bespoke provision
Have all details of this provision been shared with student and parents/carers
Has a student interview been arranged
If yes, what date is the interview scheduled for

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who will be supporting the student with this interview
How will this student travel to and from the placement
Have travel costs been considered
Are parents/carers aware if they are responsible for travel
What arrangements are in place in case any problems arise during travel for this student
Is this provision a short- or long-term placement
Who is the case worker in your school who will support this placement

First NameMiddle NameLast Name
Rationale & Outcomes
Why has your school decided that an external AP is the most suitable approach for this student?
How will this provision enhance your student’s curriculum offer?
Does this programme support a broad and balanced curriculum?
Please outline how this provision will meet the needs outlined in the student’s EHCP or Individual Learning Plan, if they have one.
Final Consents & Confirmation
Has consent been obtained from the student and parent/carer for this referral to be made?
Please confirm that your school understands an initial safeguarding visit must be completed prior to the commencement of this placement to assess suitability.
Should be Empty:

Sherlock Pathways Application Form

Referring School Details

Consent & Roll Status

Student Details

Emergency Contacts

Safeguarding & Support

Travel & Logistics

Provision Details

Rationale & Outcomes

Final Consents & Confirmation