Champions Support Network - Invitation Form

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* Are you a Parent or Carer?

Parent

Carer

Foster Carer

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* Name

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* Address & postcode of residence

Address

Address 2

Town

Postcode

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* Borough

Barking & Dagenham

Havering

Redbridge

Other (please specify)

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* Ethnicity - Tick one category that you feel best describes your ethnic origin

Asian/Asian British: Indian

Asian/Asian British: Pakistani

Asian/Asian British: Bangladeshi

Asian/Asian British: Chinese

Other Ethnic Group: Arab

Dual Heritage: White & Black Caribbean

Dual Heritage: White & Black African

Dual Heritage: White Asian

Dual Heritage: Other Background

Black/Black British: Caribbean

Black/Black British: African

White: British

White: English

White: Northern Irish

White: Scottish

White: Welsh

White: Irish

White: Gypsy, Irish Traveller or Roma

White: Other Background

Prefer not to say

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* Telephone

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* Email Address

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* Ages of the child/ren you care for

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

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* Are you worried about any of the young people you care for?

Yes

To better support your young person would you benefit from help with…

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* The education system

Yes

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* The legal system

Yes

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* The health system

Yes

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* The social care system

Yes

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* Are any of them at risk of/ or have experienced serious youth violence, exploitation and/or grooming?

Yes

Don't Know

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* Do you have any other comments?

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* How did you hear about us? (If being completed by an organisation as a referral please include the name of the organisation, staff name and a contact telephone number/email address)

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* Do we have permission to contact you?

Yes

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* If yes, how can we contact you? Tick all that apply

Phone

Letter

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