Multi Sports and Performing Arts Programme
SCHOOLS OPEN FOR SUMMER 2014
SCHOOL/ AGENCY REFERRALS ONLY
Bookings 09.30 hrs. 1st July to 17.00 hrs. 15th July 2014
1. Child/Young Person
Name of Child/ Young
Person (full name)
Gender
Date Of Birth
Disability
Yes
No
If yes please state:
Medical (Please indicate any health problems,
injuries, allergies, special needs or medical conditions)
Male
Female
Photographs (permission to take photos for promotional
purposes for LBWF only)
Yes
No
Which School Does the Child/Young Person attend?
Other Relevant Information: (please complete fully)
Is there any other information that we need to know?
i.e. Behavioural issues, nature of physical and/or
learning disability
Please also include legal status of child/YP such as
LAC or subject to any court orders.
Please ensure that you inform us of any additional
support that the child/YP may need in order to
participate in these activities (please provide clear
details of the nature of the difficulty and the level
of support they require). Use additional sheet if
required and send with application.
2. Parent/Carer details
Are you Over 16 years of age?
Full Name of Parent/Carer
No
Postcode
Address
Emergency Contact 1 - Full Name:
Relationship to Child:
Home Tel:
Work Tel:
Mobile:
Home Tel:
Work Tel:
Mobile:
Email:
Emergency Contact 2 - Full Name:
Relationship to Child
Email:
3. Referrer’s details
Name of Referrer
Job Title
Name of Organisation
Email
Contact Telephone No.
Mobile
Are you contactable
during the summer?
If not, please provide
alternative contact
Yes
Yes
No
If there is an allocated social worker or another organisation that is working with
the family please ensure you include the contact details of someone who is contactable during
the summer period.
4. Ethnicity (please place a tick next to the correct ethnicity)
White British
Black or Black British
White Irish
African
Any other White background
Caribbean
Albanian
Any other Black background
Greek/ Greek Cypriot
White and Asian
Kosovan
White and Black African
Turkish/ Turkish Cypriot
White and Black Caribbean
Any other ethnic group
Any other dual or multiple heritage
Bangladeshi
Indian
Pakistani
Any other Asian background
Chinese
Gypsy/Roma
Multi Sports and Performing Arts Programme
SCHOOLS OPEN FOR SUMMER 2014
SCHOOL/ AGENCY REFERRALS ONLY
Bookings 09.30 hrs. 1st July to 17.00 hrs. 15th July 2014
5. Session Booking (please complete the dates and activity for a place at the venue you are applying for).
Activity
Provider
Venue
Date & Time
Booking Dates
Multi Sports
Tottenham Hotspur
Walthamstow School For Monday 28th July to
Foundation
Girls, Church Hill,
Friday 15th August
Walthamstow E17 9RZ
9.30am to 3.30pm
Performing Arts X7eaven
Walthamstow School For Monday 28th July to
Girls, Church Hill,
Friday 15th August
Walthamstow E17 9RZ
9.30am to 3.30pm
Multi Sports
Leyton Orient
The Score Centre
Monday 28th July to
100 Oliver Road, Leyton, Friday 22nd August
E10 5JY
9.30am to 3.30pm
Performing Arts X7eaven
X7eaven
Monday 11th August to
569A Leabridge Road,
Friday 22nd August
Leyton, E10 7EQ
9.30am to 3.30pm
Multi Sports
Tottenham Hotspur
Heathcote School and
Monday 28th July to
Foundation
Science College
Friday 8th August
Normanton Road,
9.30am to 3.30pm
Chingford, E4 6ES
Performing Arts X7eaven
Heathcote School and
Monday 28th July to
Science College
Friday 8th August
Normanton Road,
9.30am to 3.30pm
Chingford, E4 6ES
Disability Multi
Tottenham Hotspur
Waltham Forest Pool &
Monday 11th August to
Sports and
Foundation
Track, Chingford Road,
Friday 22nd August
Swimming
Walthamstow, E17 5AA
10.30am to 3.30pm
6. Reason for referral (please tick)
Category
Common Assessment Framework (CAF)
Child in Care
Difficulties in Social Engagement
Low income families
Teenage parents
Known to Social Services
Other (Please specify):
Category
Risk of Gang Involvement
Families just below social care threshold
Welfare Concerns
Child/young person with disability
Young Carers
Known to Early Intervention Service
7. Payment Method (please tick one, Tottenham Hotspur Foundation will make contact with either party to ensure payment)
Total No: of days
Total Cost:
Payment by School/Organisation
Payment by parent/carer
I give permission in case of an emergency for my child/ren to be taken to hospital
by ambulance:
Yes
No
I give permission for my child to walk home alone (Over 8’s only):
Yes
No
Parent /Carer Signature: ……………………………………………………………….. Date ……………..............
Referrers Signature: …………………………………………………………………….
Date ……………………....
Please ensure that you complete a separate form for each child/young person
and return to Central Administrator at Tottenham Hotspur Foundation:
Post:
Email:
Tel:
Fax:
Tottenham Hotspur Foundation, Bill Nicholson Way, 748 High Road, London N17 0AP
lbwfbookings@tottenhamhotspur.com
020 8365 5138 (Enquiries only Monday-Friday 9:30am-5:30pm)
020 8365 5053