Parent Authorisation Form - Appendix D- Early Years Pupil Premium (EYPP)

FORM: PAF APPENDIX D (Parent/Carer to complete) Parent Authorisation Form - Appendix D - Early Years Pupil Premium (EYPP) This form must be completed in addition to the basic Parent Authorisation Form.

Child’s Name Child’s DOB

Your childcare provider may be able to claim EYPP additional funding to support your child’s development and learning if you meet at least one of the eligibility criteria. For details about the criteria please speak to your childcare provider or go to www.suffolk.gov.uk/EYPP.

1. PARENT/CARER DETAILS Please provide your details below to enable the economic eligibility check for EYPP to be completed. Parent/Carer 1 Parent/Carer 2 Title (please select) Mr Mrs Miss Dr Other Mr Mrs Miss Dr Other Legal Forename Legal Surname Gender (please select) Male Female Not specified Male Female Not specified DOB (dd/mm/yyyy) Relationship to Child Parental Responsibility Yes No Yes No National Insurance Number / National Asylum Support Service Number Address

Postcode

2. NON-ECONOMIC ELIGIBILITY CRITERIA

Is your child adopted from care? Yes No

Has your child been looked after by the Local Authority for 1 day or more? Yes No

Is your child subject to a Child Arrangement Order, Special Guardianship Order (SGO) Yes No or Residence Order?

3. PARENT / CARER AUTHORISATION

4. You must agree to the following declarations before your childcare provider can claim EYPP for your child. Please mark the box to show you agree.

I understand that the information I have provided can be shared with the Local Authority and The Department for Education, who will access information from other government Yes, I agree departments to confirm my child’s eligibility and enable this provider to claim Early Years Pupil Premium on behalf of my child. I agree that if I would like to withdraw my consent for checking EYPP eligibility I should Yes, I agree contact my childcare provider.