Children Missing Education Referral Form

Schools – Please complete parts 1 & 2. Other – Please complete part 1 only

PART 1

Child’s details
Forename(s)	Gender	Male/female
Surname	UPN
AKA	Year group
Date of Birth	Specific information	CIN/CP/EHA/SEN/EHC LAC-please indicate placing authority:
Ethnicity	First language
Address	Postcode

Parent/carer’s details
Forename(s)	Forename(s)
Surname	Surname
Relationship	Relationship
Phone	Phone
Mobile	Mobile
Email	Email
Address (if different)	Address (if different)
Postcode	Postcode

Any known sibling’s details (please copy and paste this section for each sibling)
Forename(s)	Gender	Male/female
Surname	UPN
AKA	Year group
Date of Birth	Specific information	CIN/CP/CAF/SEN/EHC LAC-please indicate placing authority:
Ethnicity	First language
Address(if different)	Postcode

Current school information
School	Tel. No.
Address	Email address
Last date attended	Reason for leaving

Details of Referral: Please include as much information as possible.
Name of referrer	Organisation Name	Position of referrer
Contact No.	Email address
I have read and followed the CME guidance

PART 2

If this is a school referral – Please complete this section also.

ABSENCE DAYS- 1-10- ACTION TAKEN BY SCHOOL
Date	Outcome
1st day contact
CME safeguarding checklist completed. (refer to guidance)
2nd day contact & Emergency contact numbers
Letter to Parent/carer
School Attendance Officer informed
Enquiries of wider school community E.G. Staff, pupils, friends
Home visit
Any other relevant information.

Please ensure all parts of the form are completed. Incomplete forms will be not be accepted.

Please return the forms, using one of the following methods:

a secure email : cme@herefordshire.gov.uk

anycomms+ to Herefordshire Council ‘children missing education’

Referrals may also be posted, but this may delay response time.

Admissions and CME Officer

Plough Lane, Hereford, HR4 0LE