• Child Referral

  • Who must complete this form?

    For safeguarding and legal reasons, referrals for children and young people under 18 must be completed by an appropriate adult or authorised professional. You can complete this form if you are a parent, legal guardian, designated carer, or a professional supporting the child, such as a social worker, GP or teacher.

  • Child's/Young Person's Details

  • Personal

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Medical

  • Is the child currently receiving any medical treatment?*
  • Is the child taking any prescribed medication?*
  • Will the child need our staff to give or manage any medication while they are in our care?*

  • If yes, please ensure all medication is clearly labelled with the child's full name, dosage, and frequency of use.

  • Is the child allergic to any medication?*
  • Does the child have any other allergies (e.g. foods, insect stings, environmental triggers)?*
  • Has the child received a Tetanus vaccination in the last five years?*

  • If we ever need to call emergency services, medical staff may perform immediate, life-saving care without waiting for consent. We will always contact you straight away, as any further treatment or surgery will require parental or carer approval.

  • Other Support Needs

  • Every child is welcome here. To help us tailor our support and make sure the child feels comfortable and included, please let us know if any of the following apply to the child:
  • Does your child have a diagnosed learning disability or are they currently undergoing an assessment?*

  • Parent's/Referrer's Details

  • Permission to leave text or voicemail:*

  • Additional Information

  • Is the child currently being seen by any other service?*

  • Agreement

  • By signing below, I confirm that:

    • I am a parent, legal guardian, designated carer, or authorised professional with appropriate legal authority or responsibility for the child.
    • The information provided is accurate and complete to the best of my knowledge.
    • I give explicit permission for the named child to participate in the activities, assessments, and sessions offered by Lite-Waves.
    • I give consent for Lite-Waves to contact me, as well as to store and process all personal data in accordance with our Data Protection Policy and Procedures.

  • Media & Photography Consent

  • We periodically take photos and short videos during programme activities to document progress, highlight achievements, and support fundraising. If you are happy to included the child in this content, please let us know by selecting the options below:*

  • You can change or withdraw your consent at any time by contacting us in writing.

  • Should be Empty: