Free Entitlement places for 2 year olds are limited, it is important this form is completed and returned promptly, as a child will not be allocated a place until eligibility has been confirmed. Please note, only children whose date of birth fall within the date range 1 April 2007 to 31 August 2008 can be accepted.
The pilot runs until March 2011 and at this point Thurrock Council awaits information about a possible extension of the pilot beyond this date. This means the council has funding for two terms, i.e. autumn term 2010 and spring term 2011, but not the summer term 2011. This means a gap is likely to occur between the pilot offer and the take up of the universal entitlement for 3&4 year olds.
This application form should be completed by a professional together with the family and returned to the address at the end of the form. Both the family and the professionalwill be informed of the outcome of the application and given details of the linked Children’s Centre.
Families - How we will use your Information
The information collected on this form is required in order for us to process your application for Free Childcare and to link your request with a suitable Children’s Centre. Personal information about you and your child/children will be held securely and confidentially on a database within the Early Year’s team until 2013 after which time it will be destroyed/deleted from our systems. We will use the information to send you information about free Early Education Entitlement for two year olds. Information which identifies you will be accessed on a strictly need to know basis in order to provide services to you. Your information will be shared securely with relevant Children’s Centres. All processing will be conducted in line with the requirements of the Data Protection Act (1998).
Section A: Personal details
Name of child: / Date of birth:
Name of parent/carer (1):
Relationship to child:
Address:
Postcode: / Telephone number(s):
Name of parent/carer (2):
Address (If different from above):
Postcode: / Telephone number(s):
Section B: Financial criteriaplease read guidance notes before completing
In order to qualify the familymustbe in receipt of one or more of the following (please tick all that apply):
Income Support
Income-based Jobseeker's Allowance
Child Tax Credit at a rate higher than the family element
Extra Working Tax Credit relating to a disability
Pension Credit
What documentation has been seen to confirm eligibility (e.g. Current Income Support Award Notice)? Documentation:
Section C: Additional criteria
In addition to the previous criteria, the family must have at least one of the following characteristics (please tick all that apply):
Two year olds living in households where achild or adult has a mental health, emotional or physical disability. Who has the disability child or adult (please tick)?
Family experiencing domestic violence
Family experiencing substance misuse issues
Teenage parents
Children with speech and language needs, including those with English as an additional language
Children living in temporary accommodation
Children with developmental delay
Children experiencing emotional and behavioural problems
Brief details about criteria:
Reason for request of 2 year old place (please tick all that apply):
Child’s learning/development
Child’s behaviour
Child has special needs/disability
To allow time for parent’s own learning/development
To give parent a break
Illness in family
Other, e.g. housing, domestic violence, relationships (please state)
Please provide background information to reason stated:
Is there any existing support for this child in place? If so, please tick.
Early Support
Child Protection Plan
Child in Need Plan
Common Assessment Form
Where can this information be found, as this may assist childcare providers in their care plans for the child (e.g. Family Support Team, West)?
Section D: Agency contact details
Name of agency/organisation making the application:
Address (including post code):
Name of professional: / Job title:
Email: / Telephone:
Section E: Early Years Setting and Children’s Centre details
Is this child or a sibling already with an early year’s provider? Yes No
If so, which one?
Name of nursery/pre-school/childminder attended:
Address:
The Free Entitlement for 2 year olds also offers family support as part of the package, are there any areas of help you would like that you are not currently getting?
Health
General confidence
Managing children’s behaviour
Using computers
DIY
Diet/Exercise
Housing issues
Relationships
Managing money and benefit claims
Helping children with their learning
Overcoming transport problems
Childcare
Improving your own qualifications and skills
Learning practical skills like cooking
Meeting other parents
Getting back to work
Other (please state)
What result would you like to see from getting this help (e.g. Managing children’s behaviour, “My two year old won’t sit down in their chair for more than a few minutes, I would like them to sit for longer and eat at least most of their meal without a fight.”)? Please comment:
Thurrock Children’s Centres are able to provide information about a range of help, is the family already registered with a Children’s Centre? Yes No
If so, which one? Name of Children’s Centre:
Section F: Declarations
Parent/carer declaration:
I agree that Thurrock Council may check any of the information provided on this form. I declare that the above details are true and understand that any false or incorrect information could lead to funding being withdrawn. I have read and understand the data statement above and would like my child to have funded places at a participating early year’s provider.
I consent to the information contained on this form being passed on to my nearest Children’s Centre so they can contact me about services that may be of interest to me.
Signed:
Date: / Print name:
Professional Declaration:
I confirm that I have completed this application together with the parent/carer named above and have seen evidence that they meet the financial criteria for the Free Early Education Entitlement for 2 year olds. I also confirm that in my professional opinion, this family would benefit from the childcare and family support offered through the Free Entitlement for 2 year olds.
Signed:
Date: / Print name:
Return address: 2 Year Old Pilot, Early Year’s, Children Education and Families, Civic Offices, New Road, Grays RM17 6SL.
Monitoring Form
To help us to monitor whether we are providing services in a fair way, and the Council’s equal opportunities policy is working, please complete this monitoring form. Any information you provide is confidential and will not affect how your application is assessed in any way. If you would prefer not to complete the form or parts of it you do not have to.
Asian
Bangladeshi
Chinese
Indian
Pakistani
Any other Asian background, please write in
Black
African
Caribbean
Any other Black background, please write in
White
British
Irish
Other White European Economic Area (EEA), please write in
Other White Non- European Economic Area (EEA), please write in
Mixed Heritage
Asian & Black
Asian & White
Black & Asian
Any other Mixed background, please write in
Traveller
Gypsy
Irish Traveller
Romany
Other, please write in
Other
Any other Ethnic background, pleasewrite in