JAC in a Box Placement Application

Young Person’s Details

Young Person’s Name (required)

Date of Birth (required)

Gender

MaleFemale

Disclosed disability (please specify)

GP’s name, address, and telephone number

Is there any illnesses/allergies/skin conditions we should be aware of? (If yes, please give specifics)

Referring Parties

Person making the application for placement (required)

Contact number (required)

Contact email for discussing the placement (required)

Name of parent/carer (required)

Home address

Parent/carer email (if not the referring party)

Invoice addressed to: (required)

Invoice email address (required)

Reasons for placement

What has the young person previously engaged with or has been tried already (required)

What are the reasons for seeking a placement (required)

What are the desired outcomes from the placement (required)

What are the risk factors (for example details of any known violence/aggression or past use of substances) (required)

Consent

(If young person is under 18) Date consent was given by parent/carer for this placement (required)

Young person’s comments on the placement

Declaration and consent (required)

I confirm that, to the best of my knowledge, all of the above details are correct.I consent to the provision of emergency medical treatment, if necessary.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).

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