Nursery Place Application

Section 4b(a)

FOR OFFICE USE ONLY

NURSERYDate Application Received PLACE Proof of address APPLICATION Attached Yes No Birth Cert. Attached Yes No Date of Panel Place allocated Yes No Review date Date placement begins Category recommended 1 2 3 4 5 6 7 8 Details of placement Session

NOTE: Please read the “Completion Advice Notes” to assist you in completing this form. Completed forms should be returned to the nursery of your first choice.

1 Which nursery do you wish your child to attend ?

It is important that you list up to 3 choices in priority order, we will try to offer your first choice, however, this cannot be guaranteed. If a place cannot be made available in your first choice nursery you may wish to attend another nursery this year but you must advise the head of the nursery of your first choice if you wish to remain on the waiting list this year.

1 2 3

Please indicate if you wish to split your funding between more than one nursery. Yes No If yes. please indicate the name of the other nursery (refer to guidance note 1)

2 Child Details

Forename Known As Surname D.O.B. Gender M F Address LocalExpected Authority primary Area school e.g. North entry Lanarkshiredate Council Primary School to be attended Postcode Tel. No.

3 Family Details

Person making application

Forename Surname Address Postcode Tel. No. Mobile No. Parents/Guardians Mothers Name (If different from above) Address Postcode Tel. No. Mobile No. Fathers Name (If different from above) Address Postcode Tel. No. Mobile No.

3 Family Details Cont.

Other children in the family in order of age with oldest first.

Name Age Name Age Name Age

4 Extended childcare (Children aged 3-5 years only)

Do you require extended childcare? Yes No If yes are you: A working Parent In Full Time Education If yes for how many weeks :- 52 weeks 39 weeks Other please state

Adults in household (including parents if applicable)

This should be completed for all persons over 16 who normally live in the household. Name Relationship to Employment/FT If Yes – state employer/ State number of hours worked child Education ? college details and Tel. No M T W T F S S morning afternoon morning afternoon morning afternoon

5 Place Requested

Put a tick in each of the boxes when you wish the child to attend nursery. AM or PM would be considered as 1 funded session and full day would be considered as 2 funded sessions. Mon Tues Wed Thur Fri

Full Day

6 Current Nursery/ Primary School to be Attended Does this child already attend nursery provision? Yes No If yes please give details:

Which Primary School will this child attend? What is the expected primary school entry date?

7 Ethnic background

We would like you to help us collect information about your language, religion, ethnic background and national identity. You are not required to answer the following questions, however, the information is extremely valuable as it is used to monitor the effectiveness of the council’s Race Equality Policy.

White UK White Other Asian Indian Asian Bangladeshi Asian Pakistani Asian Chinese Asian Other Black African,

Black Caribbean Black Other Gypsy Traveller Mixed Not Disclosed Not Known Occupational Traveller Other Ethnic background (Please specify) What language(s) does your child speak? Are any other languages used in your home? Child’s religion (e.g. Christian, Muslim etc) Asylum Status : Not Applicable Asylum Seeker Refugee Child’s National identity British English Scottish N.Irish Irish Welsh Other I do not wish to disclose this information.

8 Health Information

Does the child have any long-term illness, medical condition or disability? Yes No Details

I do not wish to disclose this information. If yes, has there been a professional assessment identifying a disability? Yes No If yes, can you provide copies of the professional assessments? Yes No

Child’s Doctor Child’s Health Visitor (if appropriate) Practice Practice Address Address

Postcode Tel. No Postcode Tel. No

9 Additional Information to support application.

10 To assist us in our marketing strategies please tick one of the following boxes indicating how you were informed of the application process. Local Press Postal Letter Local Primary School Council buildings (libraries, community centre etc) Friends/relations Other (please state)

11 Declaration by Applicant

The above is a true statement of my circumstances. I understand that if I give false information it will put at risk any placement offered.

I agree to inform the nursery of any changes to my circumstances as this may also affect any placement offered.

Signature Date:

Data Protection

The processing of your personal information by North Lanarkshire Council is carried out in accordance with the Data Protection Act 1998. The information contained within this form will be used to process your application for a pre school nursery place. Where appropriate we may have to share information with other departments and agencies working with or on behalf of North Lanarkshire Council. The information is held securely and treated confidentially.

To access the information held please apply in writing to the Executive Director of Learning and Leisure Service, Motherwell Civic Centre, Windmillhill Street, Motherwell ML1 1AB

Receipt Slip

Proof of Submission

Name of child

I confirm having received a nursery application form for the above child.

Signature of Staff member: Date:

Je li chc otrzyma Pa stwo kopi tego dokumentu w j zyku polskim, prosz skontaktowa si z wydzia em Early Years & Childcare pod numerem 01236 812281 lub

This application can be explained to you in Cantonese, Urdu, Hindi and Punjabi. Please contact the Bilingual Support Unit on 01236 795698. NURSERY PLACE APPLICATION

Please take the child’s birth certificate and a copy of your current year council tax bill to the nursery when you submit the completed application or send a copy with the form if you are sending your completed form by post. Send copies only as they cannot be returned. Applications cannot be processed without proof of identity.

1 Which nursery do you wish your child to attend?

You may make only one application per child, unless funding is to be split between more than one nursery, then an application should be submitted to each of the preferred first choice establishments. All applications will be recorded. Any duplicate applications will be disregarded, only the most recent form will be processed.

2 and 3 Child Details and Family Details

ContactNURSERY Details PLACE of Pre-School APPLICATION Establishments

Airdrie Local Authority

Clarkston P.S Nursery Class 01236 794800 Devonview Nursery Centre 01236 765815 Corpus Christi P.S.N/Class 01236 794843 Glengowan P.S.N/Class 01236 757670 Greengairs P.S. N/Class 01236 830587 Honeywell Nursery Class 01236 757666 New Monkland P.S.N/Class 01236 762634 Petersburn P.S. N/Class 01236 765763 Rochsolloch P.S. N/Class 01236 763643 St Andrews P.S. N/Class 01236 762622 St David’s P.S. N/Class Plains 01236 757629 St Dominic’s P.S. N/Class 01236 794818 St Edwards P.S.N/Class 01236 794830 St Serfs P.S. N/Class 01236 762781 Tollbrae P.S. N/Class 01236 762900 Victoria P.S. N/Class 01236 757713 (Incl.Gaelic Provision) Richard Stewart Nursery Centre 01236 638530