Reg Charity No 250823
Diocese of Exeter
The Mothers’ Union Incorporated by Royal Charter
Exeter Diocese
Mothers’ Union Centre
St Sidwells.
Sidwell Street
Exeter
EX4 6NN
Away From it All Holiday Scheme
Confidential Family Details
To be completed by Health Visitor/Social Worker/ Parish Priest/Doctor (please indicate which)
I nominate the following Family for a holiday under the AFIA Scheme
Surname of applicant……………………………………………Title…………………..
First name of applicant………………………………….
Address of applicant…………………………………………………
………………………………………………………………………………………………..
………………………………………………Post Code…………………Telephone……
Surname (of Additional Adult)
……………………………………………Title…………………………..
(living at the same address as above)
First name of (Additional Adult)………………………………………
Relationship to children listed below……………………………………..
Children Name…………………………………Aged ………………..
………………………………… ………………..
………………………………….. ………………….
Additional Adult ( Someone who does not live at the Applicants address)
Name………………………………………………
Address………………………………………………………………………………………………….
The completion of a further separate application and referral form will be requested from this person
Please describe any special needs identified for this family to include any physical and/or learning difficulties which may be relevant.
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Please give reasons why this family particularly needs a holiday. The reasons may include family illness or bereavement, single parents coping alone with small children, redundancy or other social factors.
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Please describe the nature of your professional relationship with this individual/family.
……………………………………………………………………………………………………………..
…………………………………………………………………………………………………………….
………………………………………………………………………………………………………………
How long have you known this individual/family in the capacity outlined above?
…………………..
Are you aware of any problems which might arise for the applicant, the holiday venue/site or Mothers’ Union if this family is offered a holiday?
………………………………………………………………………….
………………………………………………………………………………………………………………
If any problems occur during the holiday, we may need to contact you in order to seek advice about their resolution. Are you willing to be approached in such circumstances? ……………………..
Have you read the applicant’s form and to the best of your knowledge confirm that is correct YES/NO
I am happy that to the best of my knowledge the information given above is true and complete.
Signed……………………………..Position
held………………………………Contact No………….
Print Name………………………………Date…………………………….
Contact Address………………………………………………………..
……………………………………………………………………………………….Post Code
Please Note: The Mothers’ Union is not able to meet all requests, and sadly, not all applicants will be offered a holiday. As soon as your application has been considered. The Mothers’ Union will contact you to let you know whether or not a holiday is available.
If in the meantime you need to get in touch with The Mother’s Union
Please return to:
Mrs Janet Jones, 68 Barn Park, Buckfastleigh, TQ11 0AT
Janetlinda2009@yahoo.co.uk
By the 9th March 2021 at the very latest. Thank you
Telephone 01364 643627
For your information and attention
Under the 1998 Data Protection Act. the Mothers’ Union in the Diocese of Exeter needs your agreement to hold the information you have supplied for us in the connection with its charitable purposes. To copy in its entirety your answers to whoever will act as your referring agent.
(All responses of a personal nature will be treated confidentially)
To pass on contact details and other necessary information required to booking agents/holiday venue.
The Data Protection Act states that All information should be kept for no longer than necessary.
In the context of AFIA holidays it is advisable for the records to be kept for 6 years after which it will be disposed of as confidential data (if paperwork includes for example references to any serious incidents or notes of additional assessments that were undertaken, further advice would be taken before records were destroyed). All information is stored under secure conditions.
attachment
