Section 1: Child's Details

Section 2: Parent/Carer/Guardian with legal responsibility details

Parent/Carer/Guardian 1

Parent/Carer/Guardian 2

Section 3: Funding Eligibility

Please indicate which type of funding you are applying for:

Section 3a: 2 Year-Old Funding

You can only claim 2-year-old funding where eligibility criteria have been met and the claim has been approved by the Local Authority.  You must provide a copy of your eligibility known as "Passport for 2's" along with evidence of your child's date of birth.  In addition, you can only claim 2-year-old funding at settings that are registered and approved for 2-year-old funding.  If you are unsure, please speak with your childcare provider to ensure they can provide the funded hours.

Section 3b: Extended Entitlement (30 hours) for 3/4 year-olds

If you are applying for Extended Entitlement you need to apply for an Eligibility Code at www.gov.uk/apply-30-hours-free-childcare

In completing this section, I understand that the Local Authority and childcare provider will use the information provided above to verify my eligibility for Extended Entitlement (30 hours).

Section 3c: Additional Funding

Early Years Pupil Premium

The Early Years Pupil Premium (EYPP) is an additional sum of money paid to childcare providers for children of families in receipt of certain benefits.  This funding will be used to enhance the quality of their early years' experience by improving the teaching and learning and facilities and resources, with the aim of impacting positively on your child's progress and development.  For more information please speak to your childcare provider or visit www.gov.uk/get-extra-early-years-funding

Disability Access Fund (DAF)

Three and four year old children who are in receipt of child Disability Living Allowance and are receiving the free entitlement are eligible for the Disability Access Fund. (DAF).  DAF is paid to the child's early years setting per eligible child.  The purpose of DAF is to support providers to make reasonable adjustments and build the capacity of their setting to support children with disabilities.

Section 4: Setting and attendance details

You must list below all the settings your child will attend for which you will claim any early education entitlement (whether 15 or 30 hours) and you will be required to complete this declaration form with each setting your child attends.

My child will be attending the following settings:

Important:

• Your child can attend a maximum of two sites in a single day. Funding can be split across a maximum of 3 providers. If your child attends more than one setting, we will split the funding between the providers. A maximum of 10 hours funding can be provided per day


• You may be able to access the entitlement as a 'stretched offer'. This means that you can spread the hours across the calendar year rather than term-time-only, but you cannot claim more than the maximum amount for the year (570 hours universal offer) and (1140 hours extended offer). Speak to your provider if you wish to arrange this.


• If you choose to take up extra hours in excess of your funded entitlement, you will be required to pay the provider for these hours. Settings may also charge for any meals that your child has throughout the day, along with any consumables such as nappies, sun creams etc. You should be informed of any additional charges prior to signing this agreement.


• In each term there is a "Headcount" date. It is important that you speak with your childcare provider and/or the Local Authority if you are considering moving providers to ensure that your funding can be transferred. If your child moves settings prior to Headcount the funding for the term will be split between the providers based on the date of the move.  After Headcount date you will not be able to change your child's hours or change provider until the start of the following term unless you meet the criteria for Exceptional Circumstances. Exceptional circumstances include:
  
  
  
  • Safeguarding concerns based on recommendations from a St Helens Council social care or health professional
  
  
  • A change of address where the distance to the provider from a new home is more than 2 miles further than the distance from the old home
  
  
  • Multiple and significant changes placing a family in challenging circumstances at the discretion of the Local Authority
  
  
  • Where current arrangements prevent a parent accepting a job offer or a required change in shift patterns
  
  
  • Where a child's additional needs are not able to be met at the current setting
  
  
  • Where a child who has not accessed a provision before applies after the Headcount date
  
  
  
  


• If your child is involved with the Local Authority or any other agencies (e.g. Social Workers, Family Intervention Workers, and Speech Therapists etc.) you must inform the provider to ensure that my child is fully supported throughout their funded early education place.

Section 5: Data Privacy

Your childcare provider will share the information contained in this declaration form with St Helen's Council.

The Data Protection Act 2018 puts in place certain safeguards regarding the use of personal and sensitive data by organisations, including the Department for Education (DE), local authorities and schools. The Act gives rights including:

• the right to know the types of data being held


• why it is being held, and


• to whom it may be communicated

St Helen's Council processes personal data about you and your child in relation to claiming free early education entitlement funding and are "data controllers" for the purposes of the Data Protection Act 2018. In collecting your data for the purposes of checking your eligibility for universal and extended free entitlements, Early Years Pupil Premium (EYPP) or Disability Access Fund (DAF) St Helen's Council is exercising the function of a government department. St Helen's Council is authorised to collect this data pursuant to section 13 of the Childcare Act 2006.

Your data may also be shared with the School Admissions Team, Children's Centres and Health Services to help them in their service provision and assess your child's progress in this funded place.

Full details of how and why we use your data and how to exercise your rights in relation to your data can be found in the St Helen's Council Early Years Privacy Notice

Your provider(s) should also provide you with information in relation to how they will use your data.

Section 6: Declaration by Parent / Carer / Guardian with legal responsibility

I understand and agree to the conditions set out in this document and I authorise St Theresas Catholic Primary School Nursery to claim early entitlement funding as agreed above on behalf of my child.

• I confirm that all the information on this form is correct and complete to the best of my knowledge.


• I understand that if I have given misleading information on this declaration or have claimed more than the allowed entitlement, I may be asked to reimburse the provider or my child's place may be withdrawn. I understand that claiming more than the eligible entitlement may also result in court proceedings being taken against me.


• I understand that information given on this form maybe used to ensure accuracy of records across the local authority and to prevent and detect fraud.


• I understand that St Helen's Council and the provider can use my information to check my child's eligibility for 30 hours funded childcare with the appropriate government departments as allowed by law.


• I have read and understand the St Helen's Council Early Year Privacy Notice and consent to my data being processed and retained in accordance with the Data Protection Act 2018 (where consent is the lawful basis for processing).