The setting must complete this form. Please use block capitals.
General information
School/setting details
Setting name
Setting address
Name of SENCO / Contact number
Email address
Child details
Child’s name / Address
Unique pupil number (UPN) - for maintained schools only
Date of birth
Gender / Male / Female / Postcode
Ethnicity
(circle) / White British / White Irish / Other White
White and Black Caribbean / White and Black African / White and Asian / Other Mixed
Indian / Pakistani / Bangladeshi / Other Asian
Caribbean / African / Other Black Background
Chinese
Other Ethnic Minority
Traveller – Irish Heritage
Roma or Gypsy Roma
Under what category is the child accessing early education
(circle all that apply) /
2-year-old
Universal 3 and 4-year-old
Extended 3 and 4-year-old
Parent name
Relationship to child
Parent email address (All correspondence regarding the child will be cc’d to this address)
Is the child receiving any other additional funding?
DAF funding / Yes / No / Deprivation Supplement (DS) / Yes / No
EYPP funding / Yes / No / 1b/Medium Tier SEN Inclusion Funding / Yes / No
Section 2
Current assessment, provision and use of existing additional resources
(EYPP, DAF and deprivation supplement)
Please summarise current assessment of this child.(Refer to the professional documentation included as part of the application. If the child has an EHCP assessment underway attach Part B without any appendices)
Summarise how the planning for the child has supported progress. Including:
· Strategies and interventions in place
· Differentiated support and/or teaching
· Resources needed / · Arrangement for medical or care needs
· Systems for reviewing progress
· Parent Engagement
Take into account any supplement funding you are already receiving to support the child’s learning, i.e. EYPP, deprivation supplement and DAF and how you are already using this. If the child has an EHCP assessment underway, attach Part B of your request without any appendices.
Section 3
Additional provision and planned use of SEN Inclusion Fund
What additional provision do you want to develop with the funding to support this child to make progress?
Use the headings below to outline how you will spend the funding allocated to support child’s outcomes. Include any supplement funding you are already receiving to support the child’s learning i.e. EYPP, deprivation supplement and DAF.
Learning resources
Intervention programme via professionals recommended targets/outcomes
Specialist equipment recommend by professional
Enhanced ratios
Section 4
Supporting evidence
In order for your application to be considered you are required to attach the following documents and evidence. Please tick to confirm you have enclosed these with the application.
EYFS Assessment / Part B of EHCP request
(only when EHCP assessment underway)
SEN support plan
(or relevant Portage equivalent) / Assessment reports from other professionals
(1 for medium level at least 2 for higher level)
Please list the documents you are submitting as supporting evidence (and referred to in section 2)
Name of report / Date of report / Name of professional / Report Summary?
Tick if you are including Assessment Report supplementary evidence list below and attach.
Name of report / Date of report / Name of professional / Report Summary?
Section 5
Expected outcomes
In the section below please indicate the anticipated outcomes of receiving funding by ticking the relevant boxes.
Communication and Language development enhanced
Personal, Social and Emotional development enhanced
Physical development and/or Sensory development enhanced
Safety /environment improved
Improved quality of staff interaction and planning of interventions
Improved ability and skills of staff (training)
Enhanced staff ratios to enable small group work and individualised support
Parent/Legal Guardian only to complete.
Please provide any further information, views or comments about this application regarding your child
If you require any support outside of the setting, for example Parenting Support for managing behaviour and/or Home Visiting, please ask the setting to make an Early Years Referral for family Support or contact your local Children’s Centre for a wide range of support and advice.
Section 6
Evidence for meeting criteria
Please state whether you are applying for medium or high level SEN inclusion funding (Circle)
/ Medium
(1b) / High
(1c)
Please ensure you complete relevant parts of the form for
the funding level you are applying for:
Primary Areas Of Concern
Tick all that apply
Tick at least one for medium level of need funding and two for higher level of need funding / Social, Emotional and Mental Health
Cognition and Learning
Communication and Interaction
Sensory and/or Physical
Prime areas of learning Please circle to confirm child’s assessed level in accordance with criteria / 1b/Medium: At least one full ages
and stages band level below
expected (3 jumps). / 1c/High level: 2 year olds at least
12 months below expected (3 jumps).
3 year olds at least 18 months
below expected (4-5 jumps). / 4 year olds at least 24 months
below expected (6 jumps).
Communication and Language EYFS
Age / Stage Banding / Emerging / Developing / Secure
Listening and attention
Understanding
Speaking
Personal, Social and Emotional EYFS
Age / Stage Banding / Emerging / Developing / Secure
Self confidence and self awareness
Managing feelings and behaviour
Making relationships
Physical Development EYFS
Age / Stage Banding / Emerging / Developing / Secure
Moving and handling
Health and self care
Section 7
Consent
Parent/Legal Guardian to sign:
Data Protection Agreement / The information you provide will be discussed by professionals to identify the support your child needs in the setting. It will be held by Merton and may be used by the Council and other Children’s Centre partner organisations. This information will be used to help keep you informed about services for you and your family in your local area, it will also be used to help us monitor and improve those services in the future. If you have any further questions about how your information will be used, please speak to a member of the team or visit: www.merton.gov.uk/childrens_centre_database
Parent Name
Parent Signature / Date
SENCo Name
SENCo Signature / Date
Please note: we cannot accept forms without a SENCo name and signature. Forms will be returned if this is not provided.
With your consent, we are happy to correspond with the setting using email. This will be at your own risk, on the understanding that Merton Council cannot be responsible if a message sent through standard (non-encrypted) email services is accessed by an unauthorised person. You can withdraw your consent to use standard email services at any time by contacting us.
Section 8
Submitting the application
Please refer to the Merton Early Years Special Educational Needs Inclusion Fund (SENIF) Pathway
· Panel meeting dates and deadlines for submission are available on request
· Please make sure you allow sufficient time and complete your application fully, with full involvement from the family
· Incomplete applications will not be considered. If you have not answered all the questions or shown how you meet the criteria your application will be returned
· Late applications are not considered until the following Panel
· Please email the completed application form to
· You will receive written notice of the outcome of the application within 5 working days of the panel. Staff will be unable to inform you of the outcome of the application through any other means
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