Educational Placement Referral Form

Student Details

Student Name (required)

Student Date of Birth (required)

Student Address

Student Phone Number (required)

Does the student have a statement?
NoYes

Does the student have a child protection plan?
NoYes

Student Ethnicity
AsianAsian-BritishBlack-BritishBlack-AfricanBlack-CaribbeanOther Black BackgroundChineseWhite-BritishOther White BackgroundOther Ethnicity GroupDo not wish to answer

Referring School / Educational Provider Details

Name (required)

Address

Phone Number (required)

Email Address

Names and positions of key educational contacts

Names of other educational providers

Parent/Guardian Details

Who has parental responsibility for the student?

Name (required)

Address (if different to student's)

Phone Number (required)

Email Address

How are they related to the student?

Is the student joint registered with educational providers?
NoYes

Emergency Contact Details

Person 1

Name

Address

Phone Number

Person 2

Name

Address

Phone Number

Student's Medical Details

GP Name

GP Address

GP Phone Number

What medication does the student take?

Will the student need to use medication during the day and do they need support with this?

Does the student have a learning disability?
NoYes

Does the student have a physical disability?
NoYes

Does you student have a mental health problem?
NoYes

Does you client have any other health or social problem/allergies?
NoYes

Is the student accessing other health or social services?
NoYes

Why do you feel the student is suitable for Clinks Care Farm and what do you hope they will gain from their participation?

To your knowledge are there any particular barriers you feel the student may face in engaging with the Clinks Care Farm?

How long would you like the placement at Clinks Care Farm to last?

Please note we need a copy of your student's latest educational plan and risk assessment. Please upload these to us using the following fields:

Student Educational Plan

Student Risk Assessment

Funding & Payment Information

Invoice Details

Please confirm where invoices are to be sent to:

Name:

Address:

Postcode:

Phone:

I agree that the details I am submitting as the referrer are correct to the best of my ability and for Clinks Care Farm to keep these details during the length of the student's participation in the farm.

To terminate a placement we require one months’ notice in writing. If a farm helper misses a session Clinks Care Farm will charge for the day. If Clinks Care Farm cancels a session we do not charge. For further information or queries, please contact us on 01502 679134 or per email admin@clinkscarefarm.org