PARENT/CARER DECLARATION / PROVIDER AGREEMENT

PARENT/CARER DECLARATION / PROVIDER
AGREEMENT FORM FOR NURSERY EDUCATION
FUNDING FOR 2 YEAR OLDS
Period 1 Autumn Term 2016/2017 210 Hours
PLEASE COMPLETE ALL SECTIONS
Child’s Details: To be completed by parent / carer of the child
2YO Funding Reference: CPEI\
Forename:
Middle Name(s):
Legal Family Surname:
Preferred Family Surname:
Child’s Permanent Address Including Post Code:
Gender:
Male / Female
Child’s Date of Birth:
Child’s Ethnic Group (Please tick one of the boxes below)
White
Mixed
- British (WBRI)
- Irish (WIRI)
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- Traveller of Irish Heritage (WIRT)
- Gypsy/Roma (WROM)
- Italian (WITA)
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- White other (WOTH)
- White and Black Caribbean (MWBC)
- White and Black African (MWBA)
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- White and Asian (MWAS)
- Any other Mixed background (MOTH)
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- Indian (AIND)
- Pakistani (APKN)
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- Bangladeshi (ABAN)
- Any other Asian background (AOTH)
- Caribbean (BCRB)
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- African (BAFR)
- Any other black background (BOTH)
Chinese (CHNE)
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Any other ethnic background (OOTH)
Prefer not to say (REFU)
Not obtained (NOBT)
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Asian or Asian
British
Black or Black
British
Please tick the appropriate box below to state whether your child has a Special Educational Need (SEND)
SEN Support
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Education Health and Care Plan
No Special Educational Need
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Child Start Date for this
Autumn period/term:
Name of Provider:
Please confirm how many hours your child attends at this provider: (based on your child’s regular pattern of attendance)
Monday
Tuesday
Wednesday
Thursday
Friday
Funded Hours
Non- Funded
Hours
Please enter the total no. of funded hours for this period/ term
Stretched Offer: Yes/No
Start Date:
End Date:
You are entitled to claim a maximum of 210 Hours free nursery education hours within period 1 across a maximum of 2
settings. Any hours over this will be charged to you by your provider/ providers.
If your child is attending another setting, please fill in the boxes below
Name of 2nd Provider
Local Authority (if not Central Bedfordshire)
Please confirm how many funded hours your child attends the 2nd provider
Monday
Tuesday
Wednesday
Thursday
Funded Hours
only
ELIGIBLE DATES OF BIRTH FOR PERIOD 1
Central Bedfordshire Period 1 Dates:
1st September 2013- 31st August 2014
1st September 2016- 31st December 2016
Friday
Declaration and Submission:
Please tick to confirm that you understand that by signing this contract you agree with the following conditions of the Free Early
Education Entitlement.
[ ] I understand that the free entitlement must be free at the point of delivery and that I cannot be charged for this in advance.
[ ] I understand that I am entitled to claim for no more than the maximum number of free hours for each period and that any hours my
child attends over this will be charged to me by the childcare provider(s).
[ ] I have received detailed information from the childcare provider above regarding the Free Early Education Entitlement and advised
of any additional services available for my child and I understand that I will have to pay fees for these services if I want to receive them.
[ ] I understand that I cannot change provider(s) within one term of this agreement, unless the reason for it is covered by the one of the
circumstances detailed in the guidance notes of this form and I have advised the childcare provider and the Local Authority.
[ ] I confirm that my child will be regularly attending the nursery education hours as indicated above and that if my child is attending
more than one provider; all providers and the total number of hours I am looking to claim at each provider have been listed on this
form.
[ ] I understand that if I have given any false information on this declaration, I may be asked to reimburse the Provider.
[ ] I confirm that I have shown the provider proof of my child’s current address and date of birth.
[ ] I confirm that I have read and fully understood the guidance for parents/ carers completing the declaration form
Signature:
Print Name:
Data Protection Statement: The information submitted in this document is being collected by Central Bedfordshire Council for
the following purposes:
I agree to the local authority using this information to enable my child’s preschool/Nursery/ childminder to claim for
Nursery Education Funding for 2, 3 and 4 year olds and for the Early Years Annual Census data collection
The information provided may also be shared with Central Bedfordshire Children’s Centres and organisations
working in partnership with them, other local authorities and DfE. This information is Restricted when completed.
Central Bedfordshire Council ensures any personal data collected will be retained securely for as long as necessary and only
used for legitimate Council activities to facilitate the delivery of Council services, or for the purpose of preventing and/or
detecting fraud and/or crime, in accordance with the Data Protection Act 1998.
Central Bedfordshire Council’s Data Protection policy is available from the website at www.centralbedfordshire.gov.uk
Please return this form to CPEI, Watling House, High Street North, Dunstable LU6 1LF
For office use only
RFF
Completed