Initial Referral Form

Please complete this form to provide information about a young person (including yourself) you believe meets the US eligibility criteria and who would benefit from US’s support to access sport and exercise to improve their wellbeing.

Young Person's (Your) Contact Details


Call / Text / Email?


Parent / Carer's Details (if young person under 18)


About the Young Person (You)

Please tick as appropriate. One tick will indicate that the young person meets the US participant criteria. If you do not wish to provide specific details within the referral, tick the last box.


For example, communication needs, reasonable adjustments, independent travel.

Please tick any of the risks below which relate to you / the young person:

For any risks identified please provide details of these risks, including current risk management strategies.


Referrer's Details


Next Steps

Once submitted, this form will be emailed to the [email protected] mailbox.
A member of the US team will contact you to discuss this referral.
The US team will contact either the young person (you) or (your) parent / carer in the preferred way stated above.
If there will be a delay in progressing your referral, we will inform you and give an expected timescale.

Agreements

US values your privacy and is committed to protecting your data. This information will be held securely on computer and within manual files.  As a data processor we are registered with the ICO and committed to meeting the requirements of GDPR. The personal information we collect from you will mainly be used by our staff (and volunteers) at US so that they can deliver our activities and provide the best support to the young person. We will never sell or share personal information with organisations so that they can contact you for any marketing activities. US may share your information with our trusted partners and suppliers who work with us or on our behalf to deliver our services, with other groups or agencies for continuation of or new support for young people, and with bodies who have provided funding for our work with this and other young people. We may disclose your information if required to do so by law (for example, to comply with applicable laws, regulations and codes of practice or in response to a valid request from a competent authority)
- I acknowledge and consent to the above personal information handling and sharing
- I give my consent for US to use the information I have provided to offer information, advice and support to the young person named.

I give my consent for this information to be shared with US.

Please type your name here

18/07/2024