SW!TCH Referral Form

SW!TCH Referral Form
Young Person
I am filling this referral form in as a
Before we proceed, please take a moment to review the following statement and indicate your consent by ticking the boxes below.

Data consent: I confirm I have the relevant consent of the legal parent/guardian or young person to share the information in this referral form with LifeLine Projects.

I acknowledge that I have reviewed the SW!TCH Privacy Notice and agree to its terms.
Please indicate your consent.

2. Young Person’s Details
First name
Surname
Date of Birth

DayMonthYear
Phone Number
Please enter a valid phone number. If unknown please fill in with eleven 0's.Format: 00000000000.
Ethnicity
Gender
Year Group
Address

Street Address

Street Address Line 2

CityBorough

Postal Code
Borough
Parent/Legal Guardian First Name
Parent/Legal Guardian Surname
Parent/Legal Guardian's Email Address
example@example.com
Parent/Legal Guardian's Phone Number
Please enter a valid phone number.Format: 00000000000.

Additional School referral information

Please include data for the young person's previous term.
Attendance %
Authorised Absence %
Unauthorised Absence %
Attendance Notes
Behaviour

Please include data for the young person's previous term.
Number of detentions
Reports
Inclusion/Respite days
Fixed term exclusion days
Behaviour notes

1. Referrer’s Details