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Student Referral Form
Home
About Us
Core Offer
Services We Offer
Updates
Meet The Team
Our Partners – Working together with…
Health and Safety
Safeguarding
Youth Work
Alternative Education
Alternative Education Placements
Staff Observation (Word Doc)
Programme Complete Planning (Word Doc)
Research Report (PDF)
Research Report Schools (PDF)
Testimonials
Parents and Carers
Students
Careers
Contact Us
Student Referral Form
Student Referral Form
Student's Name
First
Last
*
Date Of Birth
*
School Year
*
Gender
*
Ethnicity
*
Name of Parent(s) / Carer(s)
*
Parent(s) / Carer(s) Phone Number
Parent(s) / Carer(s) Mobile Phone Number
*
Current Address
Street Address
Address Line 2
City
State / Region / Province
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao, People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Country
*
Is the student looked after?
Yes
No
If so, Address and Carer details (if different from above)
*
Is the student on a CIN / CP plan?
None
CIN
CP
*
Current Education Provider / School Provider / School address & contact number
*
Current school contact, position & contact details *
Previous School 1
Previous School 2
Referrer contact, position & contact details (if different from current school)
Other allocated agencies
*
Current education needs of student / EHCP/ Statement?
*
Does the pupil have free school meals?
No
Yes
Are there any special dietary requirements?
*
History of attendance in education
Details of health related difficulties (if any)
Details of Disabilities (if any)
Peer group relationships
Pupil – staff relationships
Home – school relationships
*
Is the pupil excluded?
No
Yes
The reason for exclusion from school (if applicable)
*
Purpose of placement
Any other supporting information (history / current needs of student).
Please email any supporting information to
[email protected]
with the student's name in the subject.
Please score the student on the following REACH attainment objectives
(1 = low – 10 = high)
*
Self Confidence
1
2
3
4
5
6
7
8
9
10
*
Engagement in education
1
2
3
4
5
6
7
8
9
10
*
Attendance
1
2
3
4
5
6
7
8
9
10
*
Motivation
1
2
3
4
5
6
7
8
9
10
*
Social Interaction
1
2
3
4
5
6
7
8
9
10
*
Resilience
1
2
3
4
5
6
7
8
9
10
Get In Touch!
Email
[email protected]
Phone
Duty Mobile: 07966 281959
Address
PO Box 37
Martock, Somerset, TA12 6WN
(This is the office address and not our student base address or address for any transport.)
Approved By
Links
Supporting LGBT young people across Somerset
Martock Online
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