Student Referral Form for Turtle Dove Alternative Education Provision
Covering a period of 8-10 weeks, with a minimum of 2 hours per fortnight, the programme will be a combination of 1:1 emotional support and practical work experience with our team at events and restaurants.
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Email *
Referring School
Contact Name
Telephone number
School Address
Name of Student
Date of Birth
MM
/
DD
/
YYYY
Age
Address
Telephone number of Student (If known)
Telephone number and names of Parent(s)/Guardian(s). Please state relationship to the Student.
Objectives/Desired Outcome
Additional Units Required
Please state all relevant health, behavioural and/or learning needs
Please state any risks we need to be made aware of
Other professionals involved and contact details
PARENTAL CONSENT
PLEASE NOTE PARENTAL CONSENT MUST BE OBTAINED IN ORDER FOR US TO PROCEED WITH THE REFERRAL
Parental consent obtained
Clear selection
Signature
Date
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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