Alternative Provision Referral Form 26/27

1 Child's Personal Details

Child's name *

First

Last

Date of birth *

Gender *

Female Male Other Prefer not to say

Nationality *

Is the child a UK resident? *

Yes No

If no, please provide more information

Address *

Has the child ever had any involvement with external agencies, either currently or in the past? *

Yes No

For example — Social Care, Early Help, CAMHS etc.

If yes, for child safeguarding purposes, please provide more information

All information provided will follow GDPR guidelines and procedures.

Does the child have any criminal convictions? *

Yes No

If yes, please provide more information

All information provided will follow GDPR guidelines and procedures.

2 Medical History

Are there any current medical conditions or allergies affecting the child that we need to be informed of? *

Yes No

If yes, please provide further information

3 Parent / Guardian Details

Parent / guardian's name *

First

Last

Parent / guardian's contact number *

Parent / guardian's email address *

Relationship to child *

4 Education

Which year group will the child be in as of September 2026? *

For all late referrals involving Year 11 students, please select 'School Leaver'.

High school attending *

Which course are you applying for? *

For all late referrals involving Year 11 students, please ensure 'School Leaver' is selected.

Does the child currently have an EHCP or learning needs? *

Yes No

If yes, please provide more information

5 Ashley Jade Education Group — Permissions

Do you give Ashley Jade Education Group permission to use photographs and videos of the child for educational purposes? *

Yes No

Please note, some images will be required as evidence for assignments within the qualification.

Do you give Ashley Jade Education Group permission to use photographs and videos of the student for social media and promotional purposes? *

Yes No

Do you give Ashley Jade Education Group permission to access your Personal Learning Record (PLR)? *

Yes No

Information held on your PLR includes your Unique Learner Number (ULN), used to register you for qualifications, as well as any previous educational achievements (e.g. GCSEs and other qualification results).

6 Professional Persons Only

If you are completing this referral on behalf of a school or external agency, please complete the information below.

Name of the professional completing this referral

First

Last

Email address of the professional completing this referral

Name of the school or external agency you are representing

Alternative Provision Application Form

1 Child's Personal Details

2 Medical History

3 Parent / Guardian Details

4 Education

5 Ashley Jade Education Group — Permissions

6 Professional Persons Only

Your cart is empty

Your cart is empty