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Refer a Young Person
You can use this form to refer yourself or to refer a young person into our service.
Young Person's Details
First name
Last name
Date of birth
Ethnicity
White English
White Northern Irish
White Scottish
White Welsh
White British
White Irish
Other White background
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background
Black Caribbean
Black African
Other Black background
Arab
Gypsy/Romany/Irish Traveller
Other ethnic group
Prefer not to say
Not provided
Any additional support needs (please describe)
Not provided
Address Line 1
Address Line 2
Town/City
County
Postcode
Reasons for referring this young person
Barriers that could affect the young person engaging in activities
Referrer Details - please leave blank if you are referring yourself
Relationship type
First name
Last name
Email
Phone number
Consent
I confirm I am happy to share this information with Croydon Voluntary Action, the lead partner for New Era Croudon
I confirm I have the permission of the young person named above to submit this form
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