top of page

Section 1 – Parent / Carer Details

Relationship to child
Parent
Carer
Guardian
Other

Section 2 – Child / Young Person Details

Birthday
Day
Month
Year

Section 3 – Sports Interest

What sport(s) is your child interested in?
Has your child previously been part of a sports team?
Yes
No
Does your child currently belong to a club?
Yes
No

Section 4 – Reason for Referral

Village United CIC supports children who are unable to access grassroots sport due to financial or personal circumstances.

Please tell us why support is being requested (tick all that apply)

Section 5 – Child’s Needs & Support

Does your child have any additional needs we should be aware of?
No
Yes (please outline below)
Any medical conditions we should be aware of?
No
Yes (please specify below)

Section 6 – Consent & Safeguarding

By completing this form, you confirm that
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Day
Month
Year

Next Steps


Once received, Village United CIC will:

• Review the referral

• Contact you if further information is required

• Match your child with a suitable grassroots club (subject to availability)


We aim to respond within 10–14 working days.

bottom of page