Referral Form

PEMBROKESHIRE SIBLING GROUP

C/o Mountain Park Farm, Lawrenny, Kilgetty, SA68 0PT . Telephone: 01834 891446

Charity Commission for England and Wales, Charity Registration No: 1076083

REFERRAL FORM

Children eligible for referral are Siblings (i.e. brothers and sisters) of children with disabilities. They must also be aged between 7 and 18 years.

The Pembrokeshire Sibling Group’s objects are:

1. To preserve and protect the good mental and emotional health of children with a disabled sibling; and

2. To provide or assist in the provision of facilities in the interests of social welfare for recreation or other leisure time occupation of such children who have need of such facilities with the object of improving their conditions of life

Relieves the stress experienced by these children within their family situations, and encourage involvement with local communities

Please complete ALL sections of the form before submitting it as any omissions may lead to a delay in the decision making process. All referrals are considered at the next trustee meeting (which are normally held monthly with the exception of August when there is no meeting). You will be advised of the decision in writing following the trustee meeting.

NB. Please print out this form or contact us at the above address for a form.

Names and Date(s) of Birth (DoB)) for child(ren) being referred.

Please state surname if different from parent/guardian.

1.…………………………………………..…………….. DOB………………

2. …………………………………………..……………..DOB………………

3. …………………………………………..……………. DOB………………

Name of recognised professional supporting the referral:

(E.g. Teacher, Social Services Professional, GP, Health Visitor or other health professional)

Job title ……………………………………………….. Telephone Number...........................................................

Signed…………………………………………………

Date....................................................

Address of parent/guardian: (Please include postcode)

…………………………………………………………………………………………. …………………………………………………………………………………………. …………………………………………………………………………………………. ………………………………………………………………………………………….

Name of parent/guardian to whom correspondence should be addressed:

Title…………………. (Mr, Mrs , Ms)

First Name or Initials………………………………………………...........

Surname…………………………………………………………………..

Telephone contact details: (Complete as applicable)

Home…………………………………….………………

Work……………………………………….…………….

Mobile....……………………………………………….....

Which contact should we use in an emergency?

(E.g. State "home", "work", "mobile number" or provide an alternative number)

…………………………………………………………….

Name(s) of disabled child (Children)

…………………………………………………………………………………. …………………………………………………………………………………. ………………………………………………………………………………….

To be eligible to receive the services of Pembrokeshire Sibling Group the referred child(ren) must have a disabled brother or sister.

Please describe the nature of the disability, or disabilities.

...............................................................................................................

In what way does the disability affect the life of the referred child(ren)? ...............................................................................................................

...............................................................................................................

I give permission for the referred child(ren) to receive the services of the Pembrokeshire Sibling Group and understand that information given will be held under the Data Protection Act for the legitimate purposes of the charity.

Signed..................................................................................(Parent/Guardian)

Date........................................................

NB Please return this form to the address at the top of the page.