Parent declaration for EE2, EE3 and 30 Hours Entitlement Parent declaration for free, EE2, EE3 and 30 hours entitlement Step 1 of 3 33% Child's Name:* First Middle Last (As shown on birth certificate)Date of Birth:* DD slash MM slash YYYY Gender:*-select from below-MaleFemaleAddress:* 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: You need to agree and complete this Declaration Form with each setting your child attends for their early education entitlement of 15 or 30 hours per week in order to ensure that funding is paid fairly between them.*Your child can attend a maximum of two sites in a single day and if your child attends more than 1 setting we will split the funding fairly between the settings. My child will be attending the following setting(s). Please enter below the total free entitlement hours attended per day. If, in future, your child’s attendance pattern changes, then a new parent declaration form must be completed and kept by your provider with previous declarations. I agree Nursery my child attends:*-select from below-Shrewsbury Nursery, E7Susuan Lawrence Nursery, E12Please select the days your child attends: Monday Tuesday Wednesday Thursday Friday Total hours per week:*Number of weeks per year (e.g. 38, 40 or 51):*Additional Information - how free entitlement hours can be used, please confirm you have read:*2 Year old and universal free entitlement for 3 & 4s totals 570 hours per year. This can be taken at 15 hours per week term time of 38 weeks or may be stretched over more weeks at fewer hours per week over 45 weeks at 12.5 hours, 47 weeks at 12 hours or 51 weeks at 11 hours where the provider offers this. Extended 30 hour free entitlement for eligible 3 & 4s totals 1140 hours per year. This can be taken at 30 hours per week term time of 38 weeks or may be stretched over more weeks at fewer hours per week 51 weeks at 22 hours where the provider offers this. I agree Additional funding may be available through EYPP, paid to providers for the provision of extra support for children of families in receipt of certain benefits. Children who are looked after or have left care of the local authority through adoption or special guardianship are also eligible. EYPP is for children aged three or four and is used to improve teaching and learning facilities and resources to impact positively on your child’s progress.*Do you wish your provider to apply for EYPP? This check will use the information supplied by you on this form or you may need to provide evidence such as a copy of an adoption certificate or a copy of the special guardianship/residence order. Yes please arrange an EYPP check No thanks 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 are eligible for the Disability Access Fund (DAF). DAF is paid to the child’s early years setting as a fixed annual rate of £800 per eligible child. The purpose is to allow providers to make reasonable adjustments and build the capacity of their setting to support children with disabilities. Is your child eligible and in receipt of Disability Living Allowance (DLA)?* Yes - Please supply a copy of award letter to allow Early Start to submit No Ethnic Origin – please help your provider to complete the Department for Education Early Years Census by indicating you child’s ethnic origin below:*-please select from below-AfghanAfrican AsianAlbanianAny Other Asian BackgroundAny Other Black BackgroundAny Other Ethnic GroupAny Other Mixed BackgroundAny Other White BackgroundArab OtherAsian and Any Other Ethnic GroupAsian and BlackAsian and ChineseBangladeshiBlack - AfricanBlack - AngolanBlack - CongoleseBlack - GhanaianBlack - NigerianBlack - Sierra LeoneanBlack - SomaliBlack - SudaneseBlack and Any Other Ethnic GroupBlack and ChineseBlack CaribbeanBlack EuropeanBlack North AmericanBosnian- HerzegovinianChineseChinese and Any Other Ethnic GroupCroatianEgyptianFilipinoGreekGreek CypriotGreek/ Greek CypriotGypsyGypsy / RomaHong Kong ChineseIndianInformation Not Yet ObtainedIranianIraqiItalianJapaneseKashmiri OtherKashmiri PakistaniKoreanKosovanKurdishLatin/ South/ Central AmericanLebaneseLibyanMalayMalaysian ChineseMirpuri PakistaniMoroccanNepaliOther AsianOther BlackOther Black AfricanOther ChineseOther Ethnic GroupOther Gypsy/RomaOther Mixed BackgroundOther PakistaniOther White BritishPakistaniPolynesianPortugueseRefusedRomaSerbianSingaporean ChineseSri Lankan OtherSri Lankan SinhaleseSri Lankan TamilTaiwaneseThaiTraveller of Irish HeritageTurkishTurkish CypriotTurkish/ Turkish CypriotVietnameseWhite - BritishWhite - CornishWhite - EnglishWhite - IrishWhite - Northern IrishWhite - ScottishWhite - WelshWhite and Any Other Asian BackgroundWhite and Any Other Ethnic GroupWhite and AsianWhite and Black AfricanWhite and Black CaribbeanWhite and ChineseWhite and IndianWhite and PakistaniWhite Eastern EuropeanWhite EuropeanWhite OtherWhite Western EuropeanYemeniDeclaration: 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