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Nursery Application
Please complete ALL sections in this form
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Email
*
Your email
Section 1: Please select which Nursery you are applying for
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Lansdowne Primary Academy (15 hour provision & 30 hour provision)
Tilbury Pioneer Academy (15 hour provision & 30 hour provison)
The Gateway Primary Free School (15 hour provision & 30 hour provision)
Hour provision required
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15 hours - AM
15 hours - PM
30 hours -
https://www.gov.uk/30-hours-free-childcare
(PLEASE NOTE TILBURY PIONEER DO NOT OFFER 30 HOUR PROVISON)
Other:
Your 30 hour valid code if required - - https://www.gov.uk/30-hours-free-childcare
Your answer
Child's Legal forename:
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Your answer
Middle name(s):
Your answer
Legal surname:
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Your answer
Date of birth:
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MM
/
DD
/
YYYY
Gender;
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Female
Male
Current address - House No. , House name (if applicable), Street, Town, County, Post Code:
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Your answer
Home Telephone No:
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Your answer
Mobile No:
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Your answer
Email Address:
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Your answer
Fill in this section if you are moving house. When are you moving?
MM
/
DD
/
YYYY
What will your new address be? House Number or House name [if applicable], Street name, Town, County, Postcode
Your answer
Name of Current Nursery:
*
Your answer
Address of Nursery including Street, Town, County, Postcode :
Your answer
Phone Number
Your answer
Date your child last attended:
MM
/
DD
/
YYYY
Section 6: Other Information - Does your child receive support for Special Educational Needs?
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Yes
No
What are the concerns?
Your answer
If YES, does your child have an Educational Health Care Plan?
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Yes
No
Have any of the following services been involved with your child in the last 3 years? Educational Welfare Officer / Social Worker / Educational Psychologist / Child & Family Support / Health Visitor / Speech and Language Therapist/ Other?
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Yes
No
If YES, please tick the appropriate box(s)
Educational Welfare Officer
Social Worker
Educational Psychologist
Child & Family Support
Health Visitor
Speech and Language
Other
Have you got concerns on your child's speech and language?
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Yes
No
If YES, please provide as much information as possible:
Your answer
Is the child 'looked after' by a Local Authority?
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Yes
No
Do you have a special guardianship/private fostering arrangement?
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Yes
No
Does your child have any siblings on roll at the GLC?
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Yes
No
Is your child entitled to Early Years Pupil Premium -
https://www.askthurrock.org.uk/kb5/thurrock/fis/advice.page?id=wAPezhDYo-Y#:~:text=The%20EYPP%20is%20an%20additional,funding%20to%20claim%20for%20EYPP
.
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Yes - a form will be completed at your child's admissions meeting
No
Section 8: Declaration - If you deliberately give false information, we may withdraw our offer of a place at one of our GLC Nurseries. All the information I have given on this form is correct. I understand that you may check this information with my child's current/previous school
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Yes
No
Relationship to the child (e.g Mother/Father/Sibling/Close relation) please specify:
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Your answer
Do you have parental responsibility for this child?
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Yes
No
Your name
*
Your answer
Your signature
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Your answer
Date
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MM
/
DD
/
YYYY
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