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Section 1 – Club Details

Sport:
Football
Swimming
Rugby
Boxing
Cheerleading
Gymnastics
Martial Arts
Horse Riding
Other

Section 2 – Referring Coach / Club Representative

Role at club:
Head Coach
Team Coach
Welfare Officer
Other
DBS status:
Enhanced DBS in place
In progress
Not applicable

Section 3 – Child / Young Person Details

Date of birth:
Day
Month
Year

Section 4 – Reason for Referral

Please outline why the child is being referred for support (tick all that apply):

Section 5 – Participation & Engagement

Attendance level:
Regular
Inconsistent
At risk of leaving

Section 6 – Safeguarding Confirmation

By submitting this referral, the club confirms:

Section 7 – Funding Understanding

By completing this form, you confirm that:

Section 8 – Declaration

I confirm that the information provided is accurate and that the referral is made in the best interests of the child.

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Date
Day
Month
Year

What Happens Next


Village United CIC will:

• Review the referral

• Contact the parent/carer for confirmation

• Assess eligibility and availability

• Confirm funding arrangements where approved


Response timeframe: 10–14 working days

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