Dear Parent or Referrer,

This form is to recommend a child for a place on a Newman Holiday Trust holiday. Please be aware that the Newman Holiday Trust is not normally able to offer holidays to children significantly outside its catchment areas, but will consider all applications.

We generally review applications between January and April for holidays in the following summer, so please be aware that referrals made outside this period may not receive a response until the next round of applications are reviewed.

Please answer as all questions to the best of your ability. If the child is selected then we will follow this form with more questions, a visit to meet the child at home and interviews with those close to the child. All information given will be treated with the utmost confidence.

*Required

About the child

Forename(s)*

Surname*

School Attended*

Date of birth*

[ 26/04/2024 ]

Female/Male*

--None--Female Male

Responsible Adult(s)

Responsible Adult(s) Forename(s)*

Responsible Adult(s) Surname(s)*

Relationship to child*

(Parent/Guardian/Foster parents)

Telephone number*

Email address*

Address Line 1*

Town/City

Postcode*

Referrer

Forename(s)

Surname

Relationship to child

Telephone number

Email address

Social/Community Worker

Forename(s)

Surname

Relationship to child

Telephone number

Email address

Who should be contacted if the application is successful?*

Responsible Adult Referrer Social / Community Worker

About the child...

Does the child have a medical problem / diagnosis?

(discuss with your nurse of doctor if you are unsure)

Does the child take tablets or medicines?

(please list name and dosage)

Please describe the family situation:

What languages do parents / carers understand?

Does the child have any communication difficulties?

Please describe

What are the child's physical needs?

Does the child have a learning disability?

Please describe

Does the child have any behavioural problems?

Please describe

How does the child react to groups?

Why do you think the child will benefit from a Newman Trust Holiday?

Has the child been on holiday with the Newman Trust before?

Where/When?

Does the child receive regular respite care?

Where/When?

How often does the child get to go on holidays or trips?

Name, address, telephone number of the child's General Practitioner/Doctor

Confirmation of application

DATA PROTECTION: The information you give will be used for the following purposes: to enable the Newman Holiday Trust, its trustees and representatives to create an electronic and paper record of your application and to enable the application to be processed. The information will be kept securely and for no longer than necessary in accordance with data protection regulations.

I am happy for my name and address to be used within the trust, and to be held by the trust in accordance with the data protection act.

I hereby apply for the child to go on a Newman Holiday Trust Holiday.

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