Refer pupils 

Welcome to the Literacy Pirates Teacher’s Initial Referral Form.

This form allows you to refer pupils to our after-school programme and is used by Literacy Pirates staff to assess the suitability of each pupil being referred.

1. The puil’s place is only confirmed once we receive and review and then notify that this pupil can be referred. We may ask to speak to your about a pupil before confirming thier place.
2. Please do not inform the young person or contact their parents at this stage. This will avoid disappointment if we decide that the child does not meet our referral criteria.
3. Information for this form should be provided by the class teacher (primary) or English teacher (secondary) of the pupil.
4. For data protection reasons please use initials not full names, and do not submit sensitive information or pupil contact details via this form. This form is for the assessment of access and learning needs only.

We look forward to working with your pupils!

School Referral Form 

Teacher Details





Referral 1

Referral 1






SBLARE - Severely Below Average Reading Age / BLARE – Below Average Reading Age / AARE – At Average Reading Age / EARE – Exceeding Average Reading Age











Referral 2

Referral 2

















Referral 3

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Referral 4

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Referral 5

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Referral 8

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Referral 9

Referral 9

















Referral 10

Referral 10

















Referral 11

Referral 11

















Referral 12

Referral 12

















Referral 13

Referral 13

















Referral 14

Referral 14

















Referral 15

Referral 15

















Referral 16

Referral 16

















Referral 17

Referral 17

















Referral 18

Referral 18

















Referral 19

Referral 19

















Referral 20

Referral 20

















Referral 21

Referral 21

















Referral 22

Referral 22

















Referral 23

Referral 23

















Referral 24

Referral 24

















Referral 25

Referral 25

















Form assembly

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