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 BackgroundWe 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
3 4 Year Old 30 Hours Free Childcare – Extended Entitlement
Please note, if you become eligible for 30 hours part-way through the term, the additional funding will not commence until the term following the date on which you receive your code.
Name of Setting
(Please complete this table for ALL childcare provision attended by your child) / Monday / Tuesday / Wednesday / Thursday / Friday / Total number of hours attended per week / Total number of hours claimed per week (Universal Entitlement) * / Total number of hours claimed per week (Extended Entitlement) *
Stretched Offer (tick if applicable)
*Please see Guidance Notes attached
My child has previously claimed funding with another Local Authority:Yes / No
Name of the Setting: ……………………………………………… Local Authority: ……………………………………..
Additional details for children claiming 30 Hours Free Childcare:
Eligibility Code ……………………………….. Parent/Carer National Insurance Number …………………………….
Declaration:
I (parent /guardian/carer) give written consent for ......
(name of the setting)
and Local Authority to use the above information, in order to verify if my child qualifies for 30 Hours Free Childcare.
Parent /Guardian/ Carer signature ……………………………………………………………………………..
Print name …………………………………………………………………………………………………………
Date ………………………………………………………….
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for on a regular weekly basis and understand that if my child does not attend on regular basis then the funding may be withdrawn.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 agreement with the Early Education Funding Privacy Notice (available at )
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 …………………………
Guidance Notes
3 4 Year Old Extended Entitlement
As well as the existing Universal Entitlement of 570 hours of free childcare per year, eligible families will be able to receive up to an extra 570 hours of free childcare to use at registered childcare settings.
The maximum number of funded hours for 30 Hours Free Childcare is 1140 per funded year.
- Term Time Only Funding - you can claim up to 30 hours per week:
-15 hours of Universal Entitlement
-Up to 15 hours of Extended Entitlement
- Stretched Offer – the number of hours claimed depends on the number of weeks a year your childcare setting is open. Please see table below:
Total number of hours available
Number of weeks / Maximum number of funded hours per week – Universal Entitlement / Remaining hours – paid in the last term of the funding year / Maximum number of funded hours per week – Extended Entitlement / Remaining hours – paid in the last term of the funding year
52 / 10.75 / 11 / 10.75 / 11
51 / 11 / 9 / 11 / 9
50 / 11.25 / 7.5 / 11.25 / 7.5
49 / 11.5 / 6.5 / 11.5 / 6.5
48 / 11.75 / 6 / 11.75 / 6
47 / 12 / 6 / 12 / 6
46 / 12.25 / 6.5 / 12.25 / 6.5