Pupil Referral Form – PiPeLine Keighley

Referrer's Details
Young Person's Details
Reasons for Referral

Referral Form V3 – Feb '24

Referring Agency: *

Address: *

Postcode: *

Name of the person referring: *

Position: *

Contact Number: *

Email *

Confirm Email

Financial Confirmation: *

Please note that while a referral will reach us, the placement cannot begin and will not be accepted from someone who does not have the financial authority make the referral.

Is this the first/only referral from your school this academic year? *

Please provide TWO email addresses for where daily registers should be sent. *

Registers email 2 *

Please provide TWO email addresses for where invoices should be sent. One of these should ideally be a finance email. *

Finance email 2 *

First Name: *

Last Name: *

Gender: *

DOB: *

Address: *

Parent/Carer name *

Main Contact Number: *

Additional Contact Number:

Ethnicity:

School:

ULN Number: *

Year group *

Predicted/Target grades (Maths, English, Literature) *

If the pupil doesn’t have predicted/target grades, please provide us with the most recent progress report.

Last progress report

Drop your file here or click here to upload You can upload up to 3 files.

Other Agencies Involved: *

Please detail agency, contact name, contact number, contact email

Safeguarding & Criminality *

This pupil has no known specific safeguarding issues, has not been charged with any crimes, and has no charges pending.
There are specific safeguarding issues around this pupil:
This pupil has been charged with a crime, has pending charges, or is under criminal investigation:

Referrer has positively confirmed that the pupil has no known specific safeguarding issues and no known issues with criminality the provision should be made aware of.

Safeguarding *

Please provide full details of all safeguarding concerns along with any procedures we may need to implement or consider.

Criminality *

Please provide us with full details of any known criminal behaviour or prosecutions. It is essential that we are provided with information regarding criminal conduct of a sexual or violent nature. This disclosure is used for us to ensure the safety of other pupils and will not prevent a pupil from being referred to us.

Essential Medical Information *

I confirm that this pupil has no known medical issues.
There are known medical issues that the providers needs to have mitigations in place for.

Referrer has positively confirmed that the pupil has no known medical issues.

Medical Information *

Please provide as much detail as possible regarding any medical needs this pupil may have.

Please check all that apply: *

Issues around poor attendance from mainstream school/provisions
Underachieving in relation to their own ability
The student has learning difficulties
Difficulties with basic literacy/numeracy
The student has been excluded from school or is at risk of becoming so
The student has suffered any form of bullying
The student holds discriminatory attitudes that PiPeLine need to be aware of
Has poor relationships with teachers
Has issues with anger or aggression
The pupil has an EHCP
The pupil has a statement

Learning Difficulties: *

Please provide learning difficulty details: *

Literacy & Numeracy: *

Exclusion: *

Bullying: *

Discriminatory Attitudes: *

Please upload a copy of the pupil’s EHCP.

Drop your file here or click here to upload

If you do not have a copy of their EHCP, this will need to be sent to us as soon as possible.

Please upload a copy of the pupil’s statement.

Drop your file here or click here to upload

If you do not have a copy of their statement, this will need to be sent to us as soon as possible.

Reasons for Referral: *

File Upload

Drop your file here or click here to upload

Upload any additional files you need.

Image Upload

Drop your file here or click here to upload

Upload any images you feel relevant.