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KickStart Booking Form
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Indicates required field
Name
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First
Last
Email
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Date of Birth
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Current Situation
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working f/t or p/t
in education f/t or p/t
not doing anything
National Insurance Number
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if not known , please state
Age
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Comments or Questions
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Post code
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Mobile Phone Number
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All referrals to KickStart must be supported by a reference from a worker from another organisation.
The worker giving the references must fill in the bottom section of this form. If you don't have someone who can give you this reference you can still join in you just need to fill in a different form so just give us a call on 01458 836130 and we can sort it out.
Name of Agency
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Worker's Contact Number
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Name of Worker
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First
Last
Worker's Email
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How do you know this young person
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How long have you known this young person?
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Offending status
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Non-Offender
Ex-offender (spent convictions)
Current Offender (unspent convictions)
non-offender = no criminal convictions of any type ex-offender = completed all sentences current offender = currently serving a community/ prison sentences / YOI, community licence conditions or under any form of supervision imposed by the courts, the police of a statutory service
Tick any conditions NOT relevant to this young person
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Drugs
Mental health
Vulnerability
Taking medication
Sexual Offences
Arson
Has caused harm to others
Has exhibited behaviour that could cause harm to others
Is a risk to others
Is a risk to staff
Has restrictions? E.g young person not allowed with others
Risk to self (self harm, attempted suicide, etc.)
More information on any issues not ticked above
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if no issue whatsoever with this young person just put "none known"
It is VN’s policy only to take referrals from workers and agencies that disclose all relevant information about individuals, so that we can support them appropriately in their volunteering. This includes health, behaviour, drugs use, history and any other relevant information. By submitting this page you confirm that all information has been declared and that you understand that by failing to disclose information about any form of risk you could potentially be committing a criminal offence under the Health and Safety at Work Act etc 1974.
Submit
