Parental Declaration Form for the purposes of Early Education Funding for 2, 3 and 4 year olds
April 2016 – March 2017
Child’s Basic Details
Male Female
I understand that my child is entitled to a maximum of 15 hours, or 25 hours if eligible for full time funding, free per week for each term (maximum of 38 weeks per year), or 570 hours accessed over an agreed number of weeks(minimum of 38 weeks per year)for which Early Education Funding can be claimed.
Please note that providers are not obligated to offer the 25 hours full time funding to age eligible children but some may choose to do so
1. I confirm that my child is attending the above provider for the following funded hours per week, per term:
Term / EligibilityAgeRange / Hours per week / Signature of parent/carer / DateSummer (commences April 16) / 15 hours – 01/04/2011 to 31/03/2014
25 hours – 01/04/2011 to 31/08/2011
Autumn (commences September 16) / 15 hours – 01/09/2011 to 31/08/2014
25 hours – 01/09/2011 to 31/08/2012
Spring
(commences January 17) / 15 hours – 01/09/2012 to 31/12/2014
25 hours – 01/01/2012 to 31/08/2012
* Please note that a minimum of 2.5 hours and maximum of 6 hours can be claimed per day, in increments of ½ hour.
** 2 year olds are only eligible for the funding if they meet additional criteria – please see for more details.
2. Additional comments (e.g. will your child be increasing or decreasing hours attended at any point during term? Enter a start date if your child starts after the beginning of term or a leave date if your child leaves before the end of term)
Summer term
Autumn term
Spring term
To ensure the best outcomes for the child Oxfordshire County Council strongly recommends accessing your entitlement at one provision only. However we recognise there may be instances where this is not possible, where this is the case you may choose to access your entitlement across a maximum of two providers registered to deliver the entitlement.
3. Does your child attend any other provider? Yes No
4. If yes, please complete the following
Name of the Provider Number of funded hours
Please note if you wish to access entitlement at a private, voluntary or independent setting and Local Authority maintained school in general most maintained nursery schools and classes will expect the full 15 hours to be taken with them, as this fits with our nursery admissions policy. No provider is obliged to agree split entitlement.
Early Years Pupil Premium - The early years pupil premium (EYPP) gives providers of early education and childcare extra funding to support eligible 3- and 4-year-olds. The childcare provider can check to see if your child is eligible using your national insurance number and date of birth. If you are happy for the provider to check this information, please include your details below
National Insurance NumberParent’s Date of Birth ______
Parental DECLARATION
If applicable, I request that my child's free early education entitlement is split between two providers detailed above. I confirm that the providers may share information about my child's progress to enable them to meet their obligations in delivering the Early Years Foundation Stage. I understand that if I have given any misleading information on this declaration or have claimed more than the entitlement with one or more providers I may be asked to reimburse the provider(s) or my child’s place may be taken away. I understand that if I choose to take less than the full entitlement for my child I agree that Oxfordshire County Council has no obligation to make arrangements to provide additional hours to ensure my child receives the maximum entitlement over the year. I understand that the information I have supplied on this form will be used to process my nursery education funding claim. It will be used by Oxfordshire County Council to compare data with other providers and maintained schools. It will also be used for statistical analysis purposes and processed in accordance with the Data Protection Act 1998.
Please choose the relevant code from the below, to describe your child’s ethnicity in the box overleaf:
Code / Description / Code / Description / Code / DescriptionAAO / Any other Asian background / CHE / Chinese / REF / Refused to give
ABA / Bangladeshi / MBA / White/Black African / WHA / Any other white background
AIN / Indian / MOT / Any other mixed background / WHB / British
APK / Pakistani / MWA / White Asian / WHR / Irish
BLB / Black Caribean / MWB / White/black Caribbean / WHT / Traveller/Irish Heritage
BLF / African / NOT / Information not obtained / WRO / Roma/Roma Gypsy
BLG / Any other black background / OEO / Any other ethnic group
Information for providers
-This declaration is your evidence of a claim and must be retained for seven years to complete claim forms and for future reference, including auditing. Please note you may be asked by the authority to produce evidence of a claim at any time.
-It is a requirement of the EYFS for providers to ‘enable a regular two way flow of information with parents and/or carers, and between providers, if a child is attending more than one setting’ (section 3.67 ‘Information and records’) by signing the below statement you are agreeing to share information with the provider name listed by the parent, if the parent has indicated they wish to split funding.
-When a child who is or becomes eligible for Early Education registers with your setting you must obtain proof of eligibility. Please indicate documents seen by ticking the relevant box below, if other appropriate document seen please specify.
Birth certificate Passport Other appropriate document (please specify)
If approved for the Early Years Pupil Premium, include reference number here
Provider Print Name:Position:
Signature:Date:
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