apply for mentoring, young people

YOUNG PERSON'S DETAILS

Name:

Address:

Telephone:

Date of Birth:

Age:

Ethnic Origin:

Black African Black Caribbean Mixed Heritage Black Other Asian Other	Indian Pakistani Bangladeshi Chinese White
Other (please specify)

PARENTS(S)/CARERS(S) DETAILS

Name:

Address:
(If different to above)

Telephone:

Mobile:

ALTERNATIVE CONTACT

Name:

Telephone:

Mobile:

Relationship to Young Person:

SCHOOL DETAILS

Name of School:

Address:

Telephone:

Key Contact Person:

Position:

Offences:

Young person has offended once
Young person is a repeat offender

School Exclusion:

Permanent
Fixed term (for days)

Reason for Exclusion:

Has the young person any specific needs/problems, including the Special Needs Code of Practice:

Is the young person gifted and talented? If so, which areas:

Key Stage Two S.A.Ts Levels:

Maths Science English

Key Stage Three S.A.Ts Levels:

Maths Science English

Has/ does the young person have/had a Learning Mentor and/or a Connexions Personnal Advisor:

Yes
No

If yes, please give more information:

Are there any issues that we should be made aware of before commencing mentoring with the young person?

Yes
No

If yes, please give more information:

If the young person has a Pastoral or Behaviour Support Plan, please attach a copy when you print this form out.