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Referral
If you or someone you know would like to become a member of Active8 please complete the form below and we will be in touch
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The person you are referring
Full Name
DOB (dd/mm/yy)
Date
Phone Number
Email address (parents/carers)
Mobile number (parents/carers)
Address
Country
- None -
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR China
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St. Barthélemy
St. Helena
St. Kitts & Nevis
St. Lucia
St. Martin
St. Pierre & Miquelon
St. Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Türkiye
Turkmenistan
Turks & Caicos Islands
Tuvalu
U.S. Outlying Islands
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Street address
Street address line 2
Street address line 3
Town/City
Postal code
Your details
Full name
Organisation/Relationship to Referee
Contact Details
Phone number
Information about the person you are referring
Education Info
School/college/university name, address, contact at school/college/university (e.g. SENCO/Tutor), course interests.
Have you discussed Active8 with the young person?
No
Yes
Have you discussed Active8 with the parents/carers?
No
Yes
Tell us about the young person
Personality, needs, interests; what is this young person like?
Does s/he have a physical impairment?
If so, roughly what is it and how does it affect him/ her?
Does he /she use a wheelchair?
Electric/ independent manual/ passenger? Need one for any distance outdoors? Need to travel in wheelchair? (If they don’t have what they need to be as active as possible, please start the ball rolling now – we know how long it takes!)
Does he/she have a learning disability?
Active8 support those with physical disabilities and not learning disabilities. However, we might be able to signpost you to other organisations if you don’t meet our criteria.
Any other health problems?
Any major social problems?
Any comments on level of co-operation/ commitment?
Young person and/or parents. Do you think they might get there regularly, and more or less with the right kit?
Anything else you’d like to tell us…
Would you like to receive our newsletter which includes updates about the charity and information about fundraising and day events for all the family?
No
Yes
Please indicate the ways in which you are happy for us to contact you :
Post
Email
Telephone
We will not share your information.
Please
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