Refer a Student Online

Referral Form

To refer a student, complete this form

Young Persons Details

Name
Address

Parents Details

Name
Address
Parental Responsibiliy(Required)
Name
Address
Parental Responsibility(Required)

School On Roll

Name
Name
MM slash DD slash YYYY
Courses Required
Number of days required 10am - 2pm
Preferred Days at Cirque (subject to availability)
Further Details(Required)
Assessment of risk(Required)
Agency Involvement(Required)
Name
Name
To refer a student with an EHCP plan, you must upload further information to allow us to review and respond with a bespoke quote based on the individual students needs
Max. file size: 50 MB.
Consent