Application toregisteras a day care provider

Before completing this application form please familiarise yourself with the following legislation:

  • Part 2 of the Children and Families (Wales) Measure 2010
  • The Child Minding and Day Care (Wales) Regulations 2010
  • The Child Minding and Day Care (Disqualification) (Wales) Regulations 2010
  • National Minimum Standards for Regulated Child Care

These can be found at

The application form is divided into two distinct parts. Both parts must be completed in full.

A checklist of additional documents that must be submitted with the application is included at the end of the application form.

Please tick preferred language of communication:

Welsh

English

Both

For office use only: QA number:

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Details of the proposed service

Nameandaddressof proposedservice
Post code
Telephone number
E-Mail address of the proposed service
Fax number (if any), of the premises where the children are to be looked after - Paragraph 26, Schedule 2

Type of service you are applying to register:

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Full day care

Sessional day care

Crèche

Out of school care

Open access play provision

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Are you applying to register as an

Individual?Organisation?

Organisation” means a body corporate or an unincorporated association(Regulation2(1))

If you are an individual applicant please complete Section A below.

If you are an organisation please go straight to Section B.

All applicants must complete Sections D, E, and F within Part 1 of the application and Part 2 of the application including Section G.

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Part1

Section A: Application made byan individual

Details asked for in this section are required under the Child Minding and Day Care (Wales) Regulations 2010 Schedule 2,Part 2, Paragraph 22

A1. This section should be completed by each individual who is proposing to be registered to provide the service and you should make as many copiesof this section as required before you complete the form. If this application is being made by an organisation, please move to Section B

Title / Mr Mrs Ms Miss Other: Please specify:
Your full name
Any aliases and former names
Date of birth
Your address
Post code
Telephone number
Email address
Do you intend to be in full day to day charge of the provision of day care? / YesNo

If the answer is no, you are required to appoint a suitable person in charge who must complete section C of this application.

A2. Qualifications and experience

Schedule1,Part2,Paragraph17andSchedule2,Part2,Paragraph22(3)

Details of your professional / technical qualifications that are relevant to the provision of day care for children under the age of 8: Schedule 2,Paragraph 22(3).
Please tell us here about any experience you have had that you think will supportyour application to provide a day care service for childrenunder the age of 8: Schedule 2, Paragraph 22(3).

A3. Please provide details below of any business you are carrying on at present or that you have carried on in the past.

Schedule2,Paragraph22(4)

Details of business / Dates you carried on this business

A4. Your work history

Schedule2,Paragraph22(5)(a)(b)(c)

Please provide details of your employment history covering the period between leaving school and now, including the year and month of each change of occupation. Remember to include periodsof study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances to enable checks to be made, if necessary.

Please be sure to include any experience you consider to be relevant to the present application including any previous work with children whether paid or not.

If any of your previous duties involved working with children, give the full reasons why your employment or position ended and please explain how this can be confirmed.

Employment
(job title) / From
month/year / To
month/year / Reason for leaving / Name, address & Tel no. of employer
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy

A5. Please supply the names and addresses of two individuals from whom we will take up references

You are not required to provide references if you are not intending to be in full day to day charge of the children in the registered setting

Schedule2,Part2,Paragraph22(5)(d)

The people you name must not be related to you. Both of these referees must be able to comment on your competence to look after children under the age of 8. Where possible, one of the referees should be your most recent employer. You should give the name of your most recent employer as the first.

Reference 1

Name
Address
Post code
Occupation
Telephone number
In what capacity areyou known tothem
e.g. employee, friend, colleague and
how long have they known you?

Reference 2

Name:
Address
Post code
Occupation
Telephone number
In what capacity areyou knownto them
e.g. employee, friend, colleague and
how long have theyknown you?

A6. Medical practitioner report

Schedule1,Part2,Paragraph18andSchedule2,Part2,Paragraph20

You are required to provide a report by a registered medical practitioner as to your physical and mental fitness to look after children under the age of 8.

This must be submitted as part of your application. A template for this reference is attached. (Appendix 1)

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of your physical and mental health.

A7. Disclosure and Barring Service (DBS) check

Schedule1,Part2,Paragraphs1920

You are required to provide a completed DBS application form when you file your application to register with CSSIW. (This must be countersigned by CSSIW on behalf of the Welsh Ministers.) Application forms are available from CSSIW regional offices.

A8. Additional Personal Information

The following information is requested under the Children and Families (Wales) Measure 2010 and the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010. A copy can be found at

Please note: You are disqualified from registration as a provider of day care or from being directly concerned in the management of any provision of day care in Wales if you or any person living or working in your household is disqualified under the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010.

CSSIW will carry out various checks, including the Disclosure and Barring Service check, local authority social services departments, and its own records.

A person is able to apply for a waiver from disqualification in certain circumstances.

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Have you or any person who lives or works in your household ever:

been refused registration in respect of achildren’s home or voluntary home? / YesNo
had your registration in respect of achildren’s home or voluntary homecancelled? / YesNo
been concerned in the management of,or had any financial interest in a children’s home or voluntary home in respect of which another person hashad their registration cancelled? / YesNo

If you answered Yes to any of the above please provide the names of the person involved, details of the relevant registration authority, name and address of thehome, nature of the person’s connection with the home, type of action taken against the person and the dateof anysuch action.

Have you or any person who lives or works in your household ever:

been refused registration in respect of the provisionof nurseries, day care, child minding or other provision of day care? / YesNo
been disqualified from registration in respectof the provision of nurseries, day care, child minding or other provision of day care? / YesNo
had registration cancelled in respect of the provisionof nurseries, day care, child minding or other provisionof day care? / YesNo

If you answered yes to any of the above please provide the names of the person involved, details of the registration authority,name and address of the provision, nature of the person’s connection withthe provision, type of action taken against the person and the date of anysuch action.

Have you or anyone who lives or works in yourhousehold ever been disqualified from fostering a child privately? / YesNo

If yes, please provide brief details here, including the name of the personand date:

Do you know of any other reason why you maybe disqualified fromregistration as a day care provider underthe Child Minding andDay Care (Disqualification) (Wales) Regulations 2010? / YesNo

If you answered yes please provide details here:

Please be aware that a failure to disclose a matter which would disqualify you from registration as a provider of day care may affect your ability to be granted a waiver.

Social services check

Please complete the attached consent form which authorises CSSIW to contact social services departments for information. (Appendix 2)

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Section B: Application made byan organisation

(e.g. registered company/local authority/limited liability partnership or unincorporated association)

B1 Details asked for in this section are required under the Child Minding andDay Care (Wales) Regulations 2010

Schedule 2, Part 2,Paragraph23

Name of organisation
Address of organisation
Post code
Telephone number
Email address of the organisation
Fax number of the organisation

B2. In the case of an applicant organisation which is a company, please provide the following information

Schedule2,Part2,Paragraph23(3)

Registered office address, post code orprincipal officeofthe company
Registered company number:
Registered charity number(if applicable):

B3. If the organisation is a subsidiary of a holding company1, please provide the following information

Schedule2,Part2,Paragraph23(4)

Name and address, post code of the holding company
Name and address, post code of the registered orprincipal office of the holding company
Name and address, post code of any other
subsidiary of the holding company

B4. You are required to provide the additional information listed below with your application

Schedule2,Part2,Paragraphs43to45

  • Copies of the last two annual reports for your organisation
  • If your organisation is a subsidiary of a holding company you will need to attach copies ofthe last two annual reports (if any) of the holding company and of any other subsidiary of the holding company
  • The last annual accountsof the organisation, if any.

1 Thewords‘holdingcompany’and‘subsidiary’aretobeinterpretedinaccordancewithSection1159oftheCompaniesAct2006

B5.1 Nominated responsible individual

Schedule1,Part2,Paragraphs21to25

This section should be completed by the person nominated as the responsible individual.

[A responsible individual is responsible for the supervisionand management of the provision of day care. In relationto a body corporate, the responsible individual must be a director, manager, secretary or other officer of that organisation. In relation to an unincorporated association, the responsible individual mustbe an officer or member of that organisation’s governing body. The following personal informationrelates to the nominated responsible individual].

B5.2

Schedule2,Part2,Paragraph24(2)

Title / Mr Mrs Ms Miss Other: Please specify
Full name
Anyaliasesand formernames
Positionheldin theorganisation
Date of birth / dd/mm/yyyy
Address
Post code
Telephone number
Email address

B5.3Qualifications and experience

Schedule1,Part2,Paragraph22/Schedule2,Part2,Paragraph24(3)(a)(b)

Details of your professional / technical qualifications that are relevant to the provision of day care for children under the age of 8:

Please tell us here about any experience you have had that you think will support this application to provide a day care service for childrenunder the age of 8.

If there is to be a person in charge please state yourqualifications and experience relevant to the supervision and management of the provision of day care.

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B5.4Your employment history

Schedule2,Part2,Paragraph24(4)(a)(b)(c)

Please provide details of your employment history covering the period between leaving school and now, including the year and month of each change of occupation. Remember to include periodsof study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances,to enable checks to be made if necessary. Please be sure to include any experience you consider tobe relevant to the present application including any previous work with children whether paid or not.

If any of your previous duties involved working with children, give the full reasons why your employment or position ended and please explain how this can be confirmed.

Employment
(job title) / From
month/year / To
month/year / Reason for leaving / Name, address & Tel no. of employer

Please continue on a separate sheet

Please use the space below to explain any gaps in your employment record above (include dates).

B5.5Please supply the names and addresses of two individuals from whom we will take up references

Only required if you intend to also be the person in charge

Schedule2,Part2,Paragraph24(4)(d)

The people you name must not be related to you. Both of these referees must be able to comment on your competence to look after children under the age of 8. Where possible, one of the referees should be your most recent employer. You should give the name of your most recent employer as the first.

Reference 1

Name
Address
Post code
Occupation
Telephone number
In what capacity are you known to them
e.g. employee, friend,colleague and how
long have theyknown you?

Reference 2

Name
Address
Post code
Occupation
Telephone number
In what capacity are you known to them
e.g. employee, friend,colleague and how
long have theyknown you?

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B5.6Medical practitioner report

Schedule 1, Part 2,Paragraph 23 and Schedule 2, Part 2,Paragraph 46

You are required to provide a report by a registered medical practitioner as to your physical and mental fitness to look after children under the age of 8. A template for this reference is attached.

(Appendix 1)

This must be submitted as part of your application.

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of your physical and mental health.

B5.7Disclosure and Barring Service (DBS) check

Schedule1,Part2,Paragraphs24and25

You are required to provide a completed DBS application form when you file your application to register with CSSIW. (This must be countersigned by CSSIW on behalf of the Welsh Ministers.)

Application forms are available from CSSIW regional offices.

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Section C. Information about the person in charge

Schedule1,Part2,Paragraphs26to31andSchedule2,Part2,Paragraph25

Thissectionappliestoapersoninchargewhoisnottheapplicantortheresponsibleindividual.

C1a.

Paragraph25(2)

Title / Mr Mrs Ms Miss Other: Please specify:
Full name of the person in charge
Any aliases and former names

C1b.

Paragraph 25(2)

Date of birth
Address
Post code
Telephone number
Email address

C2. Qualifications and experience

Schedule1,Part2,Paragraph28andSchedule2,Paragraph25(3)

Details of professional / technical qualifications that are relevant to the provision of day care for children under the age of 8

Please tell us here about any experience the person in charge has had that you think will support this application.

C3. Work history

Schedule2,Part2,Paragraph25(4)(a)(b)(c)

Please provide details of the person in charge’s employment history covering the period between leaving school and now, including the year and month of each change of occupation. Rememberto include periods of study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances, to enable checks to be made if necessary.

Please be sure to include any experience you consider to be relevant to the present application including any previous work with children, whether paid or not.

If any previous duties of the person in charge involved working with children give the full reasons why the employment or position ended and please explain how this can be confirmed.

Employment
(job title) / From
month/year / To
month/year / Reason why employment ended / Name, address & Tel no. of employer
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy
mm/yyyy / mm/yyyy

Please continue on a separate sheet

Please use the space below to explain any gaps in employment record above (include dates)

C4. Please supply the names and addresses of two individuals from whom we will take up references

Schedule2,Paragraph25(4)(d)

The people named must not be related to the person in charge. Both of these referees must be ableto comment on the competence of the person in charge to look after children under the age of 8. One of the referees should be their most recent employer, whose name should be given first.

Reference 1

Name
Address
Post code
Occupation
Telephone number
In what capacity are you known to them
e.g. employee, friend,colleague and how
long have they known you?

Reference 2

Name
Address
Post code
Occupation
Telephone number
In what capacity are you known tothem
e.g. employee, friend,colleagueand how
long have they known you?

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C5. Medical Practitioner report

Schedule1,Part2,Paragraph29,Schedule2,Part2,Paragraph46

You are required to provide a report by a registered medical practitioner as to the physical and mental fitness of the person in charge to look after children under the age of 8. A template for this reference is attached. (Appendix 1)

This must be submitted as part of your application.

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of the physical and mental health of the person in charge.

C6. Disclosure and Barring Service (DBS) check

Schedule1,Part2,Paragraphs30and31

You are required to provide a completed DBS application form in respect of the person in charge when you file your application to register with CSSIW. (This must be countersigned by CSSIW on behalf of the Welsh Ministers.)

Application forms are available from CSSIW regional offices.

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