Schools & Local Authority Shop Community Projects

Local Authority - Young Person Referral Form

Are you a School or Local Authority?

CERA Cycloan's Alternative Educational Provisions are aimed at re-engaging learners in a very practical way, supporting and empowering them to set their own goals whilst working within a structured curriculum. Our provisions are designed to improve a learner’s confidence and self-esteem, and help them develop the life skills they need to consider a new pathway.

Visit our School and Local Authority page to find more information about the engaging educational classes we offer.

If you are considering a referral in to us for a learner to access one of our engaging Alternative Educational Provisions, please give us a call first to discuss and arrange an induction for the learner allowing them to make an informed choice in regards future attendance.

Please note: Once completed and submitted, our referral form is a binding document committing you to fulfill your booking, we would advise you to complete the following before you make your referral:

• Speak with us about a proposed booking

• Ensure your young person has had a free induction

• Ensure you have funding in place to satisfy the booking

Referrals

I confirm I have permissions from my service to refer a student.

I confirm the funding required to make this referral is in place.

Which service are you referring from?




Who is making this referral?





YesNo
If yes, what date did the student have an induction?:

Who Is Being Referred?









Please tick which of the following workshops the student would like to attend:

Cycle TechnicianArt and DesignBusiness and IT

Please Tell Us All Risk Factors


YesNo


YesNo
If yes, please give detail:


YesNo


YesNo


YesNo
If yes, please detail medication:


YesNo
If yes, please explain Conditions:


YesNo
If yes, please tell us more:




YesNo

When Would You Like The Referral To Start From and Finish?




I'm unsure about an end date, please contact me to arrange a bespoke arrangement


TuesdayWednesdayThursdayFriday

Feedback and Reporting Contacts


Billing Information







If The Student Has An EHCP - please attach a copy here:
Please attach any risk assessments here:

It is important that we receive the correct information to ensure the correct levels of knowledge and support are in place i.e. 1 to 1 supervision and general safeguarding procedures.

Please Note: Once referred if the individual's behaviour does not match the risk factors detailed on this referral form, you will be contacted, this may result in fees being altered to match the Risk factors, Risk Assessments or Educational Health Care Plan needs.

I've read and understood the above statements, and all information above is correct to the best of my knowledge


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