REQUEST FOR DISCRETIONARY FUNDING FOR EARLY YEARS SETTINGS

Requests should be typed/word processed.

Section 1
Surname: / Male/Female:
Also known as: / Date of Birth:
Forename(s): / Date of admission to Early Years Setting/School:
Home address:
Postcode:
Is this a Looked After Child? Yes/No

Name of Parent / Carer with day-to-day responsibility for the child:

Mr / Mrs / Miss / Other / Surname:
Forename/s: / Relationship to Child:
Telephone (Home): / Telephone (Work):
Home Language: / Religion:
Please detail any special arrangements needed when communicating with parent/carer:

Name of other adults with responsibility for the child:

Mr / Mrs / Miss / Other / Surname:
Forename/s: / Relationship to Child:
Home address (if different to above)
Postcode: / Telephone (Home):
Telephone (Work):

Early Years Setting / School:

Name & contact:
Maintained/non-maintained:
Telephone: / Address:
Postcode:
Number of hours per week child attends and how many sessions and number of hours of Discretionary Funding requested
N.B Settings can only apply for FEE [Free Early Entitlement] funded hours
Is this child FEET [Free Early Entitlement for two yr olds] funded?
Number of children in group and attendance ratio:
Please state whether you have applied for and received an Early Years Inclusion Grant for this financial year and how this funding is being used.
Please give the reasons why discretionary SEN funding is required and explain and map how this additional support would be used:

Section 4 Agreement for request

Essential attachments (tick box if attached)
The child’s most recent information and Pathway Plan
Any other professional reports to support the application [Please list additional reports attached]
Manager of Early Years Setting
I confirm that this child’s needs require additional support not available from within the setting’s resources.
I confirm that I have consulted and sought advice from Surrey Family Services Supporting Children Team to meet this child`s needs. [Name of SEND Advisor ]...... is aware this request is being made.
Name:
Signed:………………………………………….
Date:
Parent / Carer (if views are available)
Views about your child’s progress with the support provided to date.
I agree with this request for discretionary funding being made by the nursery
Parent / Carer’s signature(s):…………………………………… Date:

Please send form to: SEN Admin,

SW & NW Quadrant Court, 35 Guildford Rd, Woking GU22 7QQ

SE Consort House, 5-7 Queensway, Redhill RH1 1YB

NE Elmbridge Civic Centre, High Street, Esher KT10 9SD

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