Parent Declaration for Free, EE2, EE3 and 30 Hours Entitlement

Child's Name:*
First Middle Last
(As shown on birth certificate)
Date of Birth:*
DD slash MM slash YYYY
Gender:*
Address:*
Street Address Address Line 2 City ZIP / Postal Code
2 year old funding approval number, if applicable, please enter Golden Ticket number or EY number:
30 hours Funding for eligible 3 and 4 Year olds, if applicable, please enter 11 digit eligibility code: Note: All children are entitled to 15 hours funded entitlement from the term after the 3rd birthday. Proof of date of birth must be given above.
Parent/Carer 1 Name:*
First Last
Paren/Carer 1 Date of Birth:*
DD slash MM slash YYYY
Parent/Carer 1 NI or NASS number:*
Parent/Carer 2 Name:
First Last
Paren/Carer 2 Date of Birth:
DD slash MM slash YYYY
Parent/Carer 2 NI or NASS number:

Ethnic Origin – please help your provider to complete the Department for Education Early Years Census by indicating you child’s ethnic origin below:*
Declaration: I confirm that the information I have provided above is accurate and true. I understand and agree to the conditions set out in this form and I authorise Early Start Education Ltd to claim free entitlement funding as agreed on behalf of my child. I confirm that my child is attending the above provider for the specified funded hours per week per funding period.*
- I Confirm
Parent/Carer Name:*
First Last
Parent/Carer Signature*
Date
DD slash MM slash YYYY
GDPR
I agree that Early Start Education can hold my hold information and that I have read the Privacy Notice. Your information will never be shared with 3rd party providers.
A link to our privacy notice can be found here: Privacy Notice

Parent declaration for EE2, EE3 and 30 Hours Entitlement