Inspires Tuition

School Referral form

Referring school

Student name

Date of birth

School year

Attendance

Working at levels

Please highlight

English

Maths

Science

EHCP

SEN

FSM

Early Help

CIN

LAC

In cases where students are CP/LAC, the AP provider would expect to attend a multi-agency meeting prior to offering a place in order to ensure they can meet the student’s needs.

Medical needs.

Is this student known to the police?

Yes No

School main point of contact

Name

Phone

Attendance officer

Name

Phone

Designated safeguarding lead

Name

Phone

SENDCo

Name

Phone

Contact details for social worker

Name

Phone

Contact details for any other agencies supporting the student:

Name

Phone

Parent/carer name

Home address

Contact phone number

Email address

Agree who will be the first point of contact with parent/carer

School AP

Signature that parent/carer agrees to this placement & is aware of the providers’ policies and expectations:

Referring school to complete: what are your aims for choosing this alternative provision? What are the outcomes you hope to achieve?

Views of the student:

Student signature

Agreed start date

Hours per week

Review date

School Referral form

Working at levels

School main point of contact

Attendance officer

Designated safeguarding lead

SENDCo

Contact details for social worker

Contact details for any other agencies supporting the student:

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