PLymouth Early Years SEN inclusion fund application form

To support a child or cluster of children in an Early Years setting

Version 1 – October 2016 OFFICIAL: SENSITIVE

PLYMOUTH CITY COUNCIL

Please read guidance notes before completing this form

Part 2

Section A – Child’s details

Please note that even if an application is for more than one child (cluster funding) Part 2 will still need to be completed for each child.

Child’s name
Date of birth
Child’s home address and postcode
Date child started in setting
Is child in receipt of 2, 3 or 4 year old funding?
How many hours per week does the child attend the setting?
Is the child accessing stretched funding?
Does the child attend another setting, If Yes which one?
Is the child looked after? (in public care)
Is the child on a child protection/child in need plan?
Does the child have English as an Additional Language (EAL)
Is there a Team Around Me/Family (TAM/TAF) in place for this child/family?
Has a proposal been made for an EHC assessment?
Does the child have an Education Health and Care (EHC) Plan?

Section B - Support services involved with the child

(i.e. Health Visitor, Children’s Centre, Advisory Teacher, Educational Psychologist, Specialist Support Worker, Speech Therapist, Physiotherapist, Occupational Therapist etc.)

Service involved / Name of professional / Are you currently working alongside this service?

Section C – Summary of child’s strengths and needs

Please complete this in consultation with parents/carers

Strengths
Needs
Any other information that you or parents/carers wish to be considered as part of this application

Section D – Each application should include the following evidence (please tick)

Application for funding – Part 1 (only one per setting)
Application for funding – Part 2 (one for each child included in application)
Recent summative assessment for each child
Recent Individual Education Plan (IEP) for each child
Outcomes based plan (TAM/EHC) with reviews if available
Other reports or relevant supporting evidence

Section E – Parental consent

I give consent for this application to the SEN Inclusion Fund panel to help support the needs of my child in their early years setting. I confirm that I have been involved in the completion of this form and I am happy that any relevant information is shared with members of the SEN Inclusion Fund panel.

Signed: ……………………………..…...... Parent/carer Date: …………

Please send completed forms to: SEN Inclusion Fund Administration, Lower Basement, Windsor House, Tavistock Road, Plymouth, PL6 5UF or e-mail

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