Please complete your information in full. You will only need to complete box number 2 (in blue) if you are eligible to access 30 hours and have an 11 digit eligibility code. 2 year old starts from the term after second birthday – (universal 15 hour funding) 3 & 4 year old starts from the term after third birthday – (extended 15 hour funding) 3 3 & 4 year old starts from the term after third birthday and – an eligibility code has been issued. Name of Childcare Provider: Child’s Details Forename Middle Name(s) Surname Name by which child is known (if different) Date of Birth Gender Female Male (dd/mm/yyyy) Documentary Document recorded proof of DoB type by (staff member name) (e.g. birth and date document certificate, recorded passport) (dd/mm/yyyy) Special Educational Needs (tick which one applies) SEN Support Education Health and Care Plan Additional details for children claiming 30 free childcare (to be completed by parents who are eligible to access 30 hours) 30 eligibility code: National Insurance (e.g 50005678912) Number I agree that the information I (PRINT name)……………………………………………………………………………………………………… have provided above can be shared with the Local Authority and Department for Education, who will access information from other government departments to check the validity of my 30 hours eligibility code. (Please refer to the data privacy notes on page 4) Parent/Carer/Guardian with legal responsibility Print Signed Name Date Child address details
Please complete your information in full. You will only need to complete box number 2 (in blue) if you are eligible to access 30 hours and have an 11 digit eligibility code. 2 year old – starts from the term after second birthday 3 & 4 year old (universal 15 hour funding) – starts from the term after third birthday 3 3 & 4 year old (extended 15 hour funding) – starts from the term after third birthday and an eligibility code has been issued. Name of Childcare Provider: Child’s Details Forename Middle Name(s) Surname Name by which child is known (if different) Date of Birth (dd/mm/yyyy) Gender Female Male Documentary proof of DoB type (e.g. birth certificate, passport) Document recorded by (staff member name) and date document recorded (dd/mm/yyyy) Special Educational Needs (tick which one applies) SEN Support Education Health and Care Plan Additional details for children claiming 30 free childcare (to be completed by parents who are eligible to access 30 hours) National Insurance Number 30 eligibility code: (e.g 50005678912) I (PRINT name)……………………………………………………………………………………………………… agree that the information I have provided above can be shared with the Local Authority and Department for Education, who will access information from other government departments to check the validity of my 30 hours eligibility code. (Please refer to the data privacy notes on page 4) Parent/Carer/Guardian with legal responsibility Signed Print Name Date Child address details
PARENT_DECLARATION_FORM_20172018.docx