Participant Name Date of Birth Email (if applicable) Phone (if applicable) Mobile (if applicable) Address Contact Name for Sessions Relationship to Participant Phone Mobile Email Address School / College information Invoice Details Email Mobile Address Emergency Contact 1 Relationship to Participant Phone/Mobile Emergency Contact 2 Relationship to Participant Phone/Mobile Needs and wishes Interested in Rural Academy - Monday to Friday 9am-6pm Urban Academy - Monday to Saturday 9am-6pm (13+ years) Coaching & Mentoring - Monday to Friday 9am-6pm Preferred start date Risk assessment required: Moving & Handling Transport Behaviours Environment Other Services involved: Child Protection Child in Need Early Help CAMHS Other Social Worker/Professional Local Authority Team & Role Medical Health Needs (incl. allergies) Has the participant been subject to any of the following: Alcohol & substance misuse Child sexual exploitation Self-harm Criminal exploitation Depression/suicidal thoughts Domestic violence/abuse Radicalisation Entering Youth Justice System Details (current or historic) Permission (do you give permission for Circles Network to make photos/videos of the participants sessions) Yes No If 'Yes' please indicate how they may be used: Website or social media Publicity material (ie leaflets) Publicity material used by our funders (print or online) Newspapers or magazines to help fundraising Shared internally with staff Are you happy for us to retain and use the participants photo/video for five years after it was taken? Yes No Send
