Refer Young People – Mentoring Service

Are you a professional referral agency?

Yes
No

is this a family refferal

Yes
No

Is the young person aged between 16 and 24?

Yes
No

Do you have consent from the young person, family or carer

Yes
No

Is the young person happy to have a regular, weekly friendly meetings with our matched mentor?

Yes
No

Referrer Name

First

Last

Referrer Phone Number

Referrer Email

Name of young person

First

Last

Young Persons Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Which borough does the young person live in?

Young Persons Email

Young Persons Phone Number

Equality and Diversity

Aishah Help wants to meet the aims and commitments regarding equality and diversity for our young people. This includes not discriminating under the Equality Act 2010, and building an accurate picture of the make-up of the volunteers in encouraging equality and diversity. The organisation needs your help and co-operation to enable it to do this:

Young Persons Gender

Young Persons Date of birth

Young Persons Ethnicity

More about young person

Please tell us about the young person

What skills would the young person like to develop with the mentor?

Does the young person speak any other language?

Which of these best describes the young persons current situation

What days & time of the week is the young person available?

Emergency Contact Person for Young Persons

Name

First

Last

Phone

Consent form

In order for us to work with you, we need to record your personal details and information about the service(s) you are partcipating in. To comply with the Data Protection Act (2018) and the GDPR we must tell you how we use this data and ask for your permission. By ticking the boxes and signing this form you are providing your permission for us to process your data for the purposes below.

Data Sharing Agreement

I consent to my data being collected and stored and shared with relevant authorities.

True and correct

I confirm that the information I have supplied is true and correct to the best of my knowledge. I understand that any false or undisclosed information could result in the closure of my application for assistance.

Legal and Preference: Keeping in touch

Telephone
Email
SMS
Letter

We would like to keep you posted on our latest news about financial help available, our work, appeals and campaigns. Please let us know how you would like to hear from us: