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Full Circle Education - Short Term Exclusion Referral Form 2010

This form is to be used by professionals seeking to refer a young person to Full Circle Education for a ‘Short Term Exclusion
Referral’. By signing this document, you are committed to funding the duration of the placement. The follow process must be
adhered to in order to negotiate and secure a Short Term Exclusion placement:

1. Please contact Damon Moore (Project Manager) to explore the availability of spaces 0208 8562050/ 07834 156482
2. Complete the form below (a separate form for each student being referred) and either fax or e-mail to Damon Moore
or Angela Young at: ( FAX) 0208 8562050 / e-mail: Fullcircle.ed@btinternet.com

School/Referring Agency Name:

Name of Referring Contact:

Contact Details Landline: Mobile:

E-mail Address

Name of Referred Student:

Gender: Male: Female:

Academic Year Group: 7 8 9 10 11

Student Home Contact Details: Name of Parent/Guardian: Home Telephone:

Home Address: Mobile Telephone:

Work Telephone:

Emergency Contact Number:

Duration of Exclusion in Days: Start Date: End Date:

Reason for Short-Term Exclusion

Any additional information (SEAN,


Family background,
medical/medicine requirements,
LAC etc.)
Is the student eligible for Free YES NO
School Meals?
Please outline any work the student
needs to complete in our care:

Signature of referring lead: Date:

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