Free early education for three and four year olds full time place

Application form 2015-16

Section 1: Child and family

Child’s details:
Forename: / Surname:
Date of Birth:
Unique Pupil Reference (School based):
National Health Number: / Ethnicity:
Address:
Postcode:
Parent’s/carer’s contact details:
Forename:
Indigo P parents numbers; / Surname:
Address (if different to the above):
Postcode:
Tel No: / Email:

Criteria for a place (please tick which category applies to the child)

Child looked after / ¨
Child is subject to a Special Guardianship Order / ¨
Child staying in a refuge / ¨
Child subject to a child protection plan / ¨
Social care involvement / ¨
The child has an early support family service plan in place / ¨
The child is subject to a CAF / ¨
Child in Need / ¨
Family in Crisis (Please give more details on additional sheet without this the application cannot be approved) / ¨

Section 2: Early years setting details

Setting Name:
Ofsted/school number:
PVI free early education number(FEE): / Tel. No:
Email (for confirmation of a place):
Spring term Summer term Autumn term ( please circle)
Closed for half term? Y/N
Start date: End date:
Number of hours per week:
If the child is attending two settings please give the name and FEE number of the other setting:
Section 4: Parental/carer Agreement
Parent’s agreement:
This is an application for a full time place. You will also be offered further support services via your local children’s centre. We need to share the details supplied on this form with your chosen early years setting and your local children’s centre, so that we can fully support you.
Please tick all statements to confirm your acceptance of the terms and conditions to the place and sign below; failure to confirm your acceptance will lead to the offer of a place being withdrawn.
I confirm that the information about my family circumstances are correct / ¨
I understand that this full time place will be initially for one term / ¨
I will participate in appropriate family support activities / ¨
Parent’s/carer’s signature: / Date:
Children centre manager
The children’s centre manager is responsible for ensuring that the parent understands the remit of the scheme and that the Family Star tool will be completed before an application can be approved. Please note that a referral does not guarantee a place.
Children centre manager signature:
Name of children’s centre:
Family Star tool completed Yes/No / Date:
Please return the completed application form via Herts FX to Please put full time place application in the subject line.
Childhood Support Services will confirm the place within 10 working days by email.
For Office use only:
Date processed / Approved Y/N
Childhood Support Officer name