Appendix C – Kingsland Nursery

PARENT DECLARATION FORM EARLY YEARS ENTITLEMENT

1. Child Details

Child's Legal First Name *

Child's Legal Family/Surname *

Name by which the child is known (if different from above)

Date of Birth *

Gender *MaleFemale

Address *

Postal Code *

Documentary proof of Date of Birth Type *

Upload an image of Documentary proof

No file chosen

Eligibility code *

2. Childcare Provider and Attendance Details

My child is attending the following setting

Provider Name *

Please enter total free entitlement hours attended per day

Monday

Tuesday

Wednesday

Thursday

Friday

Total number of hours per week

Please add hours less than or equal to 30

3. Disability Access Fund Declaration

Three- and four-year old children who are in receipt of child Disability Living Allowance and are receiving the free entitlement for three and four year olds are eligible for the Disability Access Fund (DAF).

Is your child eligible and in receipt of Disability Living Allowance (DLA)? *YesNo

If your child is splitting their free entitlement across two or more providers please nominate the main setting where the local authority should pay the DAF

4. Parent/Carer/Guardian with Legal Responsibility Declaration

Declaration

Name *

Address *

Postal Code *

Date of birth *

National Insurance number *

confirm that the information I have provided above is accurate and true. I understand and agree to the conditions set out in this document and I authorise Kingsland Nursery to claim free entitlement funding as agreed above on behalf of my child. In addition, I also agree that the information I have provided can be shared with the local authority and Department for Education, who will access information from other government departments to confirm your child’s eligibility and enable this provider to claim Early Years Pupil Premium (EYPP) or Disability Access Fund (DAF) on behalf of my child.

5. Data PrivacyKingsland Nursery and London Borough of Hackney will handle the information you have provided in line with the provisions of the Data Protection Act 2018. Any personal information will be held in confidence with only the necessary people able to see or use it. The Council will retain your information in accordance with the Council’s retention schedule and it will be held securely The Council collects information for eligibility checking, monitoring, analysis and data collection purposes. You will be registered with the setting named above and your information may be disclosed to other government agencies responsible for providing services under legislation relating to children. By signing the form it is understood that you understand and consent to the purposes for which the information may be used.

To submit form please add maximum 30 hours/week