Witham Referral Form School DetailsSchoolKey School ContactContact NumberArea of Learning RequestedPersonal DetailsFirst NameSurnameDate of BirthGenderMaleFemaleYear GroupHome AddressPostcodeParent NameMobile NumberParent NameMobile NumberWho is learner living with?Learners BackgroundBackgroundYoung OffenderLearner with DisabilityPoor AttenderExcludedTravellerAt risk of exclusionPregnantLearning Difficulties / DisabilitiesDoes the learner have an Education Health Care Plan?YesNoDoes the learner have any learning difficulties and /or disability or health problem?YesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details4 - Visual impairmentYesNo7 - Profound complex difficultiesYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details8 - Social and emotional difficultiesYesNo9 - Mental health difficultyYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details10 - Moderate learning difficultyYesNo11 - Severe learning difficultyYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details12 - DyslexiaYesNo13 - DyscalculiaYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details14 - Autism spectrum disorderYesNo15 - Asperger’s syndromeYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details16 - Temporary difficulty after illnessYesNo93 - Other physical disabilityYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details94 - Other specific learning difficulty (e.g. Dyspraxia)YesNo95 - Other medical condition (For example epilepsy, asthma, diabetes)YesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting details96 - Other learning difficultyYesNo97 - Other disabilityYesNoIf yes, please provide any supporting detailsIf yes, please provide any supporting detailsWhich of these do you consider to be the learner’s primary needs?Special Needs InformationIs there an ILP in place?YesNoAdditional information attached (if required)YesNoUpload file for additional informationChoose FileNo file chosenDelete uploaded fileHealthIs the learner taking any medication?YesNoDoes the learner have any allergies?YesNoIs the learner currently working with any other agencies to access learner support with any health issues?YesNoSafeguardingIs the learner currently working with any other agencies to access support with any safeguarding issues?YesNoDoes the learner have any caring responsibilities?YesNoDoes the learner feel safe from harm?YesNoIs there a current Child Protection Plan in place?YesNoSupport NeedsBase Line Information: Key Stage 3 Test ResultsScore - EnglishMaths - EnglishReading AgeAttendance over last 3 MonthsIf above level not available, please give an indication of ability levels.Pen Portrait: Please give a brief overview of the learner and where they are now. Learners and parents may wish to contribute to this. Please attach a separate sheet if necessary.Does the Learner Have:A history of poor school attendance?YesNoLimited social skills?YesNoLow self-esteem and self-confidence?YesNoA lack of commitment to learning?YesNoLow aspirations, or is there evidence of limited educational progress, but not necessarily lacking in ability?YesNoDisaffection from formal school for academic or social reasons (or both)?YesNoExternal Factors limiting achievement?YesNoAny other issues? (Please give details in this space below)What is the learner expecting to achieve by attending CTP?ConsentForm completed by: Please state your full nameContact telephoneContact emailDateTo be completed by the learner then countersigned by referrer and the parent/carer.I have had the reasons for this referral form explained to me. I understand the reasons for the request and understand that my information will be shared as part of the request. I give consent for this information to be shared with all relevant CTP TRAINING ACADEMY LTD staff.Learner SignatureStart signing your signature hereYour browser does not support e-Signature field.DateSchool / referrer signature after form been sentStart signing your signature hereYour browser does not support e-Signature field.DateParent / carer signatureStart signing your signature hereYour browser does not support e-Signature field.DateImportantIf there are issues regarding the learner that CTP TRAINING ACADEMY LTD needs to be aware of, please make a full disclosure.Return InformationPlease make sure this form is fully completed before sending. This form gets sent to: Katie Hawkins - katiehawkinsctptraining@gmail.comGDPR and how we use your personal informationThe General Data Protection Regulation (GDPR) replaces the Data Protection Regulation from 25 May 2018. The Regulation aims to harmonise data protection legislation, enhancing privacy rights for individuals and providing a strict framework. By signing below, you will have consented for CTP TRAINING ACADEMY LTD to process your personal data for the sole purpose of considering your eligibility to start a course. If your Application Form is successful, we will retain the application for seven years as we have a legal and contractual obligation to do so. After the seven-year period CTP TRAINING ACADEMY LTD will then securely destroy the form. If your Application Form is unsuccessful, we will retain the form for one year and then securely destroy the form. You may withdraw your consent to our processing of your personal information for a particular purpose, however, this may affect your ability to apply for your chosen course. Submit
