Parent Funding Authorisation Form (2, 3 & 4 year old funding entitlement)

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This form collects information from parents/carers to assess and process Early Education Entitlement hours, eligibility for Early Years Pupil Premium (EYPP) and eligibility for Disability Access Fund (DAF). It is mandatory to complete a parent authorisation form for each setting your child attends for their EEE and thereafter complete a new form where there are changes to any details previously submitted. It must be completed and returned to your provider within set deadlines to be able to access the free entitlement.

If you wish to transfer your entitlement to a different provider you must give four weeks written notice to your existing provider. Your child will not be able to access their early education entitlement at a new provider until the week following the end of the four week notice period.

A false declaration may result in your early education entitlement being withdrawn.

HISN agrees to deliver free hours of early education funding as stated in this document. The claim is subject to the child being on roll and actively attending school during the funding term.

Email *

Child's full name *

Child's date of birth *

YYYY

Child's gender *

Male

Female

Home address & postcode *

Child's ethnicity (you must choose which one applies) *

Disability Access Fund (DAF)

Is your child in receipt of Disability Living Allowance (DLA)? If so the provider delivering your universal funding can claim an additional £828 DAF. This can only be claimed once in a 12 month period and cannot be split between multiple providers within the 12 month period.

Not applicable

Yes my child is in receipt of DLA. I have read and understood the above statement and nominate the above provider to claim the DAF for my child for the next 12 months. (We will ask for supporting evidence of eligibility)

Parent's Full name (Parent / Carer at child's main residence). *

Parent's NI / NASS Number (I consent for this data to be used to confirm eligibility for EYPP) *

Parent's Date of birth *

YYYY

Setting & Attendance Details Sept 2023- July 2024

Yes

Hampton Infant School & Nursery (15 hours universal M-F termtime)

Additional Childcare Provider(s)

Clear selection

Please detail name(s) and childcare hours taken with other childcare provider(s). Please enter N/A if HISN will be your only provider. *

Early Years Pupil Premium (EYPP)

Additional funding is eligibility based and is paid to early years providers for the provision of extra support for your child. EYPP is used to improve teaching and learning facilities and resources so as to impact positively on your child's progress and development. Please select if any of the below apply as your child may be eligible.

In receipt of benefits / child tax credits / universal credits (please ensure parent details above are fully completed)

The child has left care under the subject of an adoption / special guardianship / child arrangement order (please provide documentary evidence)

The child has been in local authority care for one day or more (please provide documentary evidence)

Parent / Carer / Guardian with legal responsibility please tick all below to confirm you understand and agree to the funding terms and conditions *

I confirm my child is only accessing funded entitlements at the providers declared above which includes providers from other boroughs

I understand that the school will deliver the above agreed funded hours free of charge as per the Free Early Education offer

I understand that this agreement ends on 31st August 2024 and that four calendar weeks' notice will be applied from the date I give written notice to end or amend the agreement before 31st August 2024. I will not be able to access the entitlement hours at any other provider until the week following the end date of the notice period.

I confirm the information I have given in this form is true and accurate

Required

Your name *

Date *

YYYY

Submit

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