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 leastone of the eligibility criteria. For details about the criteria please speak to your childcare provider or go to

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

1. 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)or Residence Order? / Yes No

1. PARENT / CARER AUTHORISATION
2. 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 departments to confirm my child’s eligibility and enable this provider to claim Early Years Pupil Premium on behalf of my child. / Yes, I agree
I agree that if I would like to withdraw my consent for checking EYPP eligibility I should contact my childcare provider. / Yes, I agree