Surrey Early Years Funding Disability Access Fund Form

Providers who offer three and four year old children free early years education can apply for Disability Access Funding to support children with additional needs to access free early years education. A lump sum payment of £615 per year is available to providers who have children in receipt of Disability Living Allowance and are claiming free early education.

By filling in this form you agree to Disability Access Funding being paid to one childcare provider as a one-off payment. If you move your child to another childcare provider during the year the funding will not transfer.

Please give this completed form to your childcare provider along with a copy of your child’s Disability Living Allowance letter confirmation. The childcare provider will send this form and proof of eligibility to Surrey County Council.

Child’s legal first name
Child’s legal last name
Child’s date of birth
Full postal address (including postcode)
Name of childcare provider you wish to receive the Disability Access Fund payment
Full address of provider including post code
Child’s start date

Parental consent and declaration

I declare that:

I am the parent/legal guardian of the child named on this form
The above information relating to my child is complete and accurate
I have provided evidence that my child is in receipt of Disability Living Allowance
I understand that if I move my child to another childcare provider, for any reason, that the Disability Access Fund is not transferable
My child attends and claims their free early education at the childcare provider named above
I consent to the information I have provided being passed to Surrey County Council
I understand that my personal information is held securely in accordance with the Data Protection Act 1998 and can be shared with the local authority and Department for Education, who will access information from other government departments to confirm my child’s eligibility and enable this provider to claim Disability Access Fund on behalf of my child.

Signature of parent/guardian: ...... Date ......

Provider declaration

I confirm that the child named above attends this setting and claims their free early education funding at this setting.

I have attached a copy of the child’s Disability Living Allowance letter confirmation.

Please email this form securely using Egressalong with any supporting evidence to your local SEND advisory team:

North east:

North west:

South east:

South west:

or post to: Finance & Practice Team, Surrey Family Services, Surrey County Council, Fairmount House, Bull Hill, Leatherhead, Surrey KT22 7AH.

I am aware of the advice from the ICO regarding holding personal data including sensitive personal data which is available at

Signature of Provider: ...... Date ......

Name of setting………………………………………………………………………………………

Ofsted URN…………………………………………………………………………………………...

Data Protection Act 1998. Surrey County Council (the ‘Council’) respects your privacy rights and is committed to ensuring that it protects your details, the information about your dealings with the Council and other information available to the Council (‘your information’). In accordance with the Data Protection Act 1998, the Council will use your information, for the purpose of providing support to children, to (a) deal with your requests and administer its departmental functions, (b) meet its statutory obligations, and (c) prevent and detect fraud. The Council may share your information (but only the minimum amount of information necessary to do the above and only where it is lawful to do so) with appropriate departments and agencies in accordance with Multi Agency Information Sharing Protocol (MAISP). Further details including a copy of the MAISP can be found at If you would like to apply for access to the information we hold about you please send a written request to: Supporting Families Service, Surrey County Council, Fairmount House, Bull Hill, Leatherhead, Surrey KT22 7AH.