NEWCASTLE BRIDGES SCHOOL
REQUEST FOR COMMUNITY TEACHING ON MEDICAL GROUNDS
THIS FORM MUST ONLY BE COMPLETED BY HOSPITAL/COMMUNITY PAEDIATRICIANS OR
CYPS PROFESSIONALS
The young person’s school will then be required to provide additional supporting information.
All sections marked * must be completed before submitting this form in order for it to be accepted.
*Name
*D.o.B.
*ADDRESS
*NAME OF CARER
HOME TEL. NO.
*MOBILE TEL. NO.
*POST CODE
*SCHOOL
*LEA
YR GP
*REASON FOR ABSENCE:
*HOW MANY HOURS OF EDUCATION PER WEEK CAN THIS YOUNG
PERSON ACCESS?
0-5
5-10
>10
*FOR HOW MANY WEEKS IS COMMUNITY TEACHING
REQUIRED?
*DATE OF REFERRAL
INVOLVED AGENCIES
CYPS
YOT
CSC
Other
*NAME OF REFEREE
*CONTACT
NO.
X/
Please return this form to admin@bridges.newcastle.sch.uk
You can also contact us at Newcastle Bridges School, Cherrywood, Newcastle upon Tyne NE6 4NW
Tel: 0191 2755 111 Fax: 0191 2762347