Child's Name *

    First

    Last

    Gender *

    Child's Date of Birth *

    Home Address *

    Postcode

    Child's Ethnic Origin *

    Child's Nationality *

    Child's Country of Birth *

    Religion *

    Child's First Language *

    Other Languages Spoken *

    Parent / Carer 1 Name *

    Parent / Carer 1 Title *

    Parent / Carer 1 Date of Birth

    Lone Parent *

    Parent / Carer 1 Phone Number *
    Parent / Carer 1 Email Address *

    Parent / Carer 1 Nationality *

    Parent / Carer 1 National Insurance Number *

    Parent / Carer 1 Occupation *
    Employer *

    Parent / Carer 2 Name

    Parent / Carer 2 Title

    Parent / Carer 2 Date of Birth

    Parent / Carer 2 Phone Number

    Parent / Carer 2 Email Address

    Parent / Carer 2 Address (if different from child)

    Parent / Carer 2 Nationality

    Parent / Carer 2 National Insurance Number

    Parent / Carer 2 Occupation

    Employer

    Does your child have additional needs or health issues? *
    Please give details

    Does your child receive support from the Child Development Centre, Speech and Language Therapy or other service? *
    Please give details

    Is your child “looked after” or supported by an Early Help Plan or children's Services? *
    Please give details

    Do you give permission for us to seek further information from other professionals who work with your child/family to support your application?

    Is your child accessing Disability Living Allowance (DLA)? *

    Does your child have or are they in the process of gaining an Education, Health and Care Plan (EHCP)? *

    Do you give permission for us to use your details to check your child’s eligibility for Early Years Pupil Premium under the economic criteria?

    Has your child attended any other childcare settings? e.g. childminder, relatives or another nursery setting. *
    Please give details.

    Have any of your older children attended our Nursery? If yes, with which Keyworker? *

    Preferred Start Date *

    Funding

    All 3 and 4 year old children can access Universal Free childcare of 15 hours of funded nursery education per week during term time, starting the term after the child’s third birthday.
    Working parents may be eligible for Extended Free childcare (also known as 30 hours’ free childcare) equivalent to an additional 15 hours funded nursery education per week during term time.

    For more information and to check your eligibility to funding before completing this application we recommend visiting: www.childcarechoices.gov.uk

    All funded sessions are offered term time only. The Nursery School will be closed each year for 10 closure days, 5 inset days and all statutory public holidays. A holiday club is offered outside of term time and places are subject to availability. Booking forms are sent to families each term.

    Families are responsible for applying for and providing a valid funding code prior to their child starting at the nursery. Below is the government guidance on when to apply for a code and when your child’s funding eligibility will start:

    From 3 years old a child born on or between

    Recommended time to apply

    Funding eligibility starts from

    1st April to 31st August

    1st July to 15th August

    September after their 3rd birthday

    1st September to 31st December

    1st November to 15th December

    January after their 3rd birthday

    1st December to 31st March

    1st February to 15th March

    April after their 3rd birthday

    Please answer the questions below to help us confirm your eligibility for funding:

    Extended Free Childcare for Working Families

    Do you, and any partner, expect to earn £167 per week (on average)?

    Do you, and any partner, each expect to earn less than £100,000 per year?

    Do you, and any partner, have a National Insurance Number?

    Do any of these apply?

    Do you, and any partner, have British or Irish citizenship?
    Do you, and any partner, have settled or pre-settled status (or have applied)?
    Do you, and any partner, have permission to access public funds?

    If you have answered NO to ANY of the questions above please complete Section A
    If you have answered YES to ALL of the questions above please complete Section B

    Section A – Please indicate your preference for a 15 hour Universal Funded Place

    Additional Sessions Paid Sessions
    Please request below any additional day care sessions you require during term time, subject to availability:

    8.00am – 8.30am: £4.50, includes breakfast
    MondayTuesdayWednesdayThursdayFriday

    8.30am – 11.30am: £18.00

    11.30am – 12.30pm: Hot Lunch £11.00

    11.30am – 12.30pm: Packed Lunch £6.00

    12.30pm – 3.30pm: £18.00

    3.30pm – 5.00pm: £10.50, includes tea

    Section B – Please indicate your preference for a 30 hour Extended Funded Place

    Working Families 30 hour Reference Code
    Monday to Friday between 9.30am to 3.30pm, I will provide a packed lunch for my child at no additional cost
    Monday to Friday between 9.30am to 3.30pm, I will require a hot lunch for my child at a cost of £7 per day

    Additional Sessions Paid Sessions
    Please request below any additional day care sessions you require during term time, subject to availability:

    8.00am – 8.30am: £4.50, includes breakfast

    8.30am – 9.30am: £6.00

    3.30pm – 5.00pm:£10.50, includes tea

    Signature
    Please write your name to confirm you have parental responsibility (see below) for the child named in this application.

    Definition of Parental Responsibility
    Under the Children Act 1989, the following people have “parental responsibility”:
    • the mother
    • the father if he was married to the child’s mother at the time of the child’s birth
    • the father if he registered the child’s birth jointly with the mother, has subsequently married the child’s mother, through a ‘parental responsibility agreement’ between him and the child’s mother that is registered with the court, by obtaining a court order for parental responsibility.
    • If two female parents have a child through fertility treatment, the mother’s female partner is treated in the same way as a father. She has parental responsibility if she is married to or in civil partnership with the mother or she can acquire parental responsibility in the same way that a child’s father can.

    Parental responsibility can also be acquired through: adoption or prospective adoption, by obtaining a parental order following a surrogacy, being a step-parent (through agreement with the child’s mother and their other parent or as the result of a court order), being granted a child arrangements order determining who a child should live with, being appointed as a guardian or special guardian, being named in an emergency protection order, being the local authority named in the care order for a child.