Connex Tutors Pupil Referral Form – Academic Tutors

Please complete the details below in as much detail as possible to help us prepare your programme and assign appropriate candidates.  

Pupil Name(Required)
DD slash MM slash YYYY
Does the pupil have an EHCP?
DD slash MM slash YYYY
DD slash MM slash YYYY
Max. file size: 16 MB.
Has the pupil/young person been diagnosed with any conditions which could impact their learning?
Does the young person have any medical conditions we should be aware of?

Intervention Details

Tuition subject(s)
Please identify the curriculum objectives or areas that you would like tuition to focus on.
T1
T2
T3
Are the attainment targets above part of wider exam preparation?
What is your preferred frequency?

Intervention Lead Contact Details

Contact Name(Required)

Parent/Carer Contact Details

Name of parent/carer

Finance

Permissions(Required)
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