Little Miracles Youth Club Referral Form
Thank you for providing us with this information. Due to our Data protection, your data is being saved on our secure system. We will not pass on your data to another organisations unless there is a safeguarding concern, but from time to time we may contact you to discuss being a case study for Little Miracles, this will not be done without your consent. If you do not consent to this please do not fill in this form and contact us on data@littlemiraclescharity.org.uk
Which Branch Youth Club would your child/young person like to attend?
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Please Select
Peterborough
March
Wisbech
Bourne
Child/Young Persons Name
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First Name
Last Name
Date of Birth
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-
Day
-
Month
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Carer Details
Name of Parent/Carer
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First Name
Last Name
Relationship to Child
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Contact Number
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Email Address
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About the Child
Please provide your child's full diagnosis
Please provide us with more information about any behavioural needs your child may have
Please provide us with anything else you feel may be helpful for us to know
I understand that completing this referral form will place my child on the waiting list for Little Miracles Youth Club. I acknowledge that this does not guarantee a place. I also understand that a full care plan meeting must be completed before my child can attend independently.
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Please Select
I agree to the above statement.
Submit
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