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Referral Form

Please note that Let’s Get Going is running in specific schools across Reading, West Berkshire and Slough. To check the location of your local programme contact the team on 01183 341 864 or email info@lets-get-going.co.uk

Eligibility criteria:
Child must be aged 7 – 12

Child's First name and Surname

Child’s Date of Birth

Child’s School

Child’s Gender

Child’s GP Surgery:

Parent's First name and Surname

Postcode
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Parent's Contact Number (landline)

Parent's Contact Number (mobile)

Parent's Email Address

Where did you hear about this programme?

Reasons for wanting to attend Let’s Get Going?

Other (please provide details)

Can a parent or guardian attend the final 20 minutes of each Let's Get Going session?

Further information: PAR-Q. Does your child have the following?

High or Low Blood Pressure
Elevated Blood Cholesterol

Asthma or Respiratory problems

Sustained injury/ illness
Chest Pain bought on by Physical Activity
Dizziness or Fainting

Bone/ Joint problems

Childhood Epilepsy
Taking any medication

Allergies

Does your child have any known learning difficulties, disabilities or additional needs that may require additional support?

Do you know of any reason that your child should not take part in physical activity?

If you have answered YES to any of the questions on the PAR-Q above please provide further details:

Consent to be Completed by Parent/ Guardian:

  • I consent that the information I have provided on my child’s health in accurate. I understand that my child is responsible for monitoring themselves throughout the physical activity session and should any unusual symptoms occur they should alert the instructor and cease participation in the activity.
  • I understand that as with any form of physical activity unavoidable injuries or accidents may occur. I understand that all programme staff are fully trained to deliver the LGG Programme and that all leaders have an enhanced Disclosure and Barring Service (DBS) check.
  • I understand that all information gathered during the programme will remain confidential and I agree for data to be used anonymously to evaluate the programme.
  • I understand that if my child fails to behave in a manner that is appropriate for the session that they may be asked not to return to the programme.
  • I understand that I am expected to attend the final 20 minutes of each weekly session in order to share in what my child has learnt during the session.
  • I consent to myself and my child’s picture/ video being taken within the Let’s Get Going group sessions and being used by S4H for website, social media and advertising purposes. Please note you will be informed prior to picture being taken.

I agree to all above statements above and give consent for my child to participate in the Let’s Get Going Programme