Referral Form

Child's First name and Surname

Child’s Date of Birth
-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- January February March April May June July August September October November December -- 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970

Child’s School

Child’s Gender
-- Please Choose -- Male Female

Child’s GP Surgery:

Parent's First name and Surname

Parent's Contact Number (landline)

Parent's Contact Number (mobile)

Parent's Email Address

Where did you hear about this programme?
-- Please Choose -- Letter/ Flyer from School Nurse/ GP Surgery Waiting Room Social Media/ Online From a previous service user

Reasons for wanting to attend Let’s Get Going?
I would like to take advantage of free afterschool child care
I am worried that my child’s weight is/ is becoming above what is healthy for their age/ height
My child does not participate in much activity, LGG will help them to try new things
I would like my child and family to learn the tools we need to live a healthy lifestyle long term.

Other (please provide details)

Can a parent or guardian attend the final 20 minutes of each Let's Get Going session?
Yes
No

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

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.

If you do not wish to be included in photographs please tick here

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