Individual Referral Form

  • Please complete one form for each participant joining us for a community session.  
  • Please don't hesitate to contact us if you have any queries.
Privacy Information
  • We use the information given on this form in order to process your enquiry for sessions with Mane Chance Sanctuary.
  • We will never share your information with any third parties for marketing purposes and all information about you is held safely and securely.
  • For further information on how your details are stored and used, how we maintain the security of your information and your rights to access information we hold about you, please contact us.
Referrer (parent/guardian/teacher) details
Name of Referrer *
Referrer's email address *
Referrer's contact phone number *
Participant's Details
Full Name of participant *
Date of birth of participant *
Year group of participant *
Please tell us the name of the school or college that the participant attends (if applicable)
Referral reason

Please briefly tell us why you are interested in sessions at the Sanctuary for this participant.  This helps us to understand their needs and allows us to consider which options of our provision may be of most support to you.

We do not need specific medical information - just an indication of how you think time at the Sanctuary will help.

Outline of reasons for referral
Session availability
Who will be funding the sessions?

Thank you for completing this form.

Please click submit to send us the information and we will be in touch very shortly.

Share this page
NEWSLETTER SIGN UP

Sign up here to get the latest Mane Chance news about all that is happening at the Sanctuary, find out about our events and how you can help, delivered straight to your inbox. 

First name: *
Last name: *
Email address: *

Follow us on