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Referral to City Family

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Referral Form for Parents

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Details of Parent/Carer

please only complete if present
please only complete if present
please only complete if present
DD slash MM slash YYYY
DD slash MM slash YYYY
please only complete if present
Address (Adult 1)*
Address (Adult 2)*
please only complete if present
please only complete if present
please only complete if present
Do you have parental responsibility for the child(ren) listed below?*

Adult 2: Do you have parental responsibility for the child(ren) listed below?*

please only complete if present
Are you pregnant? (optional)
Adult 2: Are you pregnant? (optional)
please only complete if present
please enter details here

Details of Child(ren)

Child's Name Date of birth Gender Actions
     

Emergency Contact Details for your Child(ren) (other than yourself)

Disability/Additional Needs (optional)

Agreement and Consent to Contact

We would like to use the information you have provided to contact you about future City Family events, news and services that we offer. If you are happy to be contacted, please tell us your preferences: Full details on how City Family CIC processes can be found within our Privacy Notice, which can be found at the bottom of this website. You can also change or withdraw your consent at any time by contacting City Family CIC at [email protected]
Adult 1: I agree to be contacted via (please choose preferred option)
Adult 2: I agree to be contacted via (please choose preferred option)
please only complete if present
Referrals will only be accepted where explicit consent from the parent/carer for City Family has been obtained and recorded.
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City Family CIC | Socata House I 543-545 London Road I Westcliff On Sea I Essex I SS0 9LJ

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Southend-on-Sea City Council

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As part of the Women in the Workplace project, funded by DHSC and run by Pregnant Then Screwed and Best Beginnings, we are excited to share that we have received an Accreditation for the Empowered Foundations training with a focus on women's reproductive health in the workplace. As part of the training, our managers accessed modules based on the topics of pregnancy loss, fertility, flexible working and eliminating bias to better understand the use of language, ways to support members of staff and increase knowledge base around these specific topics. Here at City Family we are striving to improve the support available for the women in our workplace

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