Violence Reduction Partnership – Referral – The Hive, Wirral Youth Zone

Young Persons Information and Emergency Contacts

Young Persons Name *

First

Last

Young Persons Address *

Address Line 1

City

State / Province / Region

Postal Code

Young Persons Phone Number

Date of Birth

Gender *

Male
Female
Prefer not to say
Other

Gender: Other

If your gender isn't listed and you've selected 'Other' please type it in the box above.

Additional Needs or Disabilities

Medical conditions

School

School Year *

Emergency Contact Name (Parent/Carer) *

Relationship to young person *

Emergency Contact Address

Address Line 1

City

State / Province / Region

Postal Code

Emergency Contact Phone Number *

Emergency contact email

Name of Referrer *

First

Last

Role of referrer *

Email address of referrer *

Email

Confirm Email

Reason for referral *

Pro-criminal attitudes
Pro-criminal associates – peers involved in criminal and anti-social behaviour including siblings / parents
Involved in Anti-Social Behaviour
Family issues (History of DV in the family home, parental mental health, parental substance use, disrupted relationships)
Poor attendance at School / Exclusions Substance misuse
Associating with negative peers / activities
Professional knowledge

Supporting information *

Consent

Where there is a need to protect or support a young person, we may also share personal information with relevant agencies as required by law. For further information about how we process your personal information, who we may share it with, and your rights, please read our Privacy Policy. If young person is under the age of 16, please select the under 16 option and a member of staff from the Hive Team will call the parent/carer

Do we have parent or carers permission for the young person to do all of the activities in The Hive, including but not limited to: climbing, fitness suite and boxing?

Do we have parent or carer consent for staff and volunteers at The Hive to perform first aid or emergency medical treatment?

I agree that the young persons image (in photos or videos) may be used for marketing and publicity purposes in printed publications, on social media, on the Youth Zone website or elsewhere.

I agree that my sensitive personal information may be shared with OnSide Youth Zones, suppliers, funders and/or sponsors (as required for the purposes of the development, coordination and support of the Youth Zone network. Contact us for a list. The Youth Zone will ensure that third parties agree to keep this information confidential. *

I agree that my sensitive personal information can be processed to provide me with services and carry out administration in relation to my membership. *

Violence Reduction Partnership – Referral

Young Persons Information and Emergency Contacts

Consent

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