Emergency Referral

Young person’s name (required)

Date of birth (required)

GP’s name, address and telephone number

Is there any illness/allergy/skin condition we should be aware of? (If yes, please give details)

Reason for referral to occur during pandemic (required)

Young person has an assigned social workerYoung person has an EHCPYoung person is the child of a key workerYoung person is waiting for an EHCP to be agreed or is going to tribunal to secure an EHCP

Health Questionnaire (required)

The young person and everyone in their household are free from symptoms of COVID-19The young person is healthy but they are living with a vulnerable personThe young person or someone in their household are exhibiting symptoms of COVID-19

Responsible Adult (required)

Contact phone number (required)

Contact email (required)

Is the young person happy to work outside? (required)

YesNo

Is the young person happy to work with animals? (required)

YesNo

Are there any restrictions or requests on when the young person could come for sessions? (required)

Risk factors (for example details of any known violence/aggression/flight) (required)

Reasons for referral/goal of the sessions (required)

Date consent was given by parents/carer for this referral (required)

Tick as appropriate (required)

I confirm, to the best of my knowledge, all of the above details are correctI consent to the provision of emergency medical treatment, if necessaryI consent to my child participating in JAC activities

Additional consent

I consent to photographs/videos being taken and used in publicity for JAC (where possible we will try not to have front profiles of children, but occasionally this might be the case)

For riding activities

I understand that riding at any standard has inherent risk that I may fall off and could be injured. I accept that risk and agree that the riding school will not be liable for injury or damage to property unless it is caused by their negligence. Where I am signing on behalf of a minor, I have explained it to them and we both accept the risk and agree that the riding school will not be liable for injury or damage to property unless it is caused by their negligence.