Setting Details

Name of Nursery, Pre-School or Childminder: ......

Child start date at the setting: ...... / ...... / ...... Child Details

Child’s Forename: ......

Child’s Surname: ...... Legal Surname (if different): ......

Date of Birth: ...... / ...... / ...... Gender: Male  Female 

Family Address: ......

...... Postcode: ... …......

Home telephone number: ......

Ethnic Background We are required by law to pass the following information to the Department of Education (DfE) for statistical purposes

White Black or Black British Asian British British Caribbean Indian Irish African Pakistani White Eastern European Any Other Black Background Bangladeshi White Western European Any Other Ethnic Background Any Other Asian Background White Other Mixed Chinese Portuguese White & Black Caribbean Korean Gypsy/Roma White & Black African White & Asian Prefer not to say Any Other Mixed Background

Early Education Funding

2 Year Old Funding  Eligibility Code ……………………………………….

3 & 4 Year Old Funding – Universal Entitlement (up to 15 hours per week) 

2 Year Old Funding or 3 & 4 Year Old Funding - Universal Entitlement

Stre tche d Name of Setting We Total Total Tue Thu Offe Mon dne Frid number of number of sda rsd r (Please complete this table for ALL day sda ay hours hours y ay (tick y attended claimed childcare provision attended by your if child) per week per week * appli cabl e)

* Please see Guidance Notes attached

My child has previously claimed funding with another Local Authority: Yes / No

Name of the Setting: ……………………………………………… Local Authority: ……………………………………..

Guidance Notes

2 Year Old Funding or 3 & 4 Year Old Funding - Universal Entitlement

The maximum number of funded hours for 2 Year Old Funding or 3 and 4 Year Old Funding - Universal Entitlement is 570 per funded year.

1. Term Time Only Funding - you can claim up to 15 hours per week:

2. Stretched Offer – the number of hours claimed depends on the number of weeks a year your childcare setting is open. Please see table below:

Remaining hours – paid Number of Maximum number of funded hours per in the last term of the weeks week – Universal Entitlement funding year

52 10.75 11 51 11 9 50 11.25 7.5 49 11.5 6.5 48 11.75 6 47 12 6 46 12.25 6.5 Declaration: I, the Parent/Guardian understand: Please tick  I am responsible for ensuring that my child uses the funded hours applied for on a regular weekly basis and understand that if my child does not attend on regular basis then the funding may be withdrawn. 

 I must notify the Nursery/Pre-School/Childminder of my child’s absence and the reason will be recorded in the register. For up to 2 weeks’ holiday, the Early Education Funding will not be withdrawn. However, I may be charged for any  additional weeks taken.

 If my child leaves the setting without giving the required notice period, stated in the contract between myself and the Nursery/Pre-School/Childminder, it may affect my Early Education Funding at a new setting, except where there are safety or quality concerns for which a formal complaint has been made to Ofsted and  substantiated.

 If I have any concerns regarding my child’s Early Education Funding I will attempt to resolve this with my Nursery/Pre-School/Childminder in the first instance. If my  concern cannot be resolved, I will contact my Local Authority.  If I fail to provide complete and accurate information, this may affect my claim.   I am in receipt of and in agreement with the Privacy Notice.   Personal information that I provide will be held and used in compliance with the Data Protection Act 1998 (For further information about how personal information is used please refer to the Privacy Notice. For general queries on use of data the leaflet “How we take care of and use your personal information” is available from:  The Children’s Information Service, Town Hall, Bourne Avenue, Bournemouth BH2 6DY Tel: 01202456222).

Name of Parent/Guardian: ...... (please print clearly) Relationship to Child: ......

Signature: ...... Date: ...... / ...... / ......

I confirm that, to the best of my knowledge, the Parent Declaration form has been completed correctly. Name of Childcare Provider: ......

Signature of Provider: ...... Date: ...... / ...... / ......

I confirm that I have checked child Date of Birth against Documentary proof of DoB Type (eg Birth Certificate, Passport):  (please tick) Signature of Provider: ………………………………………………. Date …………………………