Fillable Parent declaration form free early education and childcare (Hertfordshire County Council)

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Parent declaration form free early education and childcare (Hertfordshire County Council)

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Parent declaration form – free early education and childcare for two, three and four year olds
1
Privacy Notice Template
This template is provided by Hertfordshire County Council. Please note however that as the Data
Controller for the information that is being gathered
is responsible for ensuring that the information contained in the Privacy Notice is accurate and that
it complies with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018.
Further information and advice can be found at https://ico.org.uk/for-organisations/guide-to-data-
protection/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/right-to-be-
informed/
Why we need your information
The data on this form is being gathered for the purpose of delivering free early education.
is obliged to collect and process this data under the
Education Act 1996 and the Childcare Acts of 2006 and 2016, including The Education (Information
About Individual Pupils) (England) Regulations 2013.
The information you have provided will be used alongside additional information obtained from your
current and previous early years education applications where applicable. This will include
attainment information to monitor progress of each child against the Early Years Foundation Stage.
What we will do with your information
will use the information gathered in this form to agree the
childcare services to be provided to your child. In order to deliver this service we will share the
information you provide on this form with the Early Years Service team (Children’s Services) of
Hertfordshire County Council to assess your eligibility for free early education entitlements and to
derive statistics which inform decisions such as the funding of schools and early years providers.
Attainment information will be summarised and then used to target support in identified areas of
need across Hertfordshire. This is to improve outcomes and ensure that early years services are
accessible to all families.
Details of the Council’s Privacy Policy can be found at www.hertfordshire.gov.uk/privacy
Information will also be shared with The Department for Education (DfE) for statutory returns, other
departments in Children’s Services and your local Family Centre, who support the local authority by
assisting families to access the services they are entitled to.
We may also share information with third parties if we are legally obliged to do so, for example if it is
necessary to safeguard or protect a child.
We may also share information with the police or other agencies if it is necessary for the following
purposes:
a) the prevention or detection of crime
b) the apprehension or prosecution of offenders
c) the assessment or collection of any tax or duty or any imposition of a similar nature
[Provider name]
[Provider name]
[Provider name]
Parent declaration form – free early education and childcare for two, three and four year olds
2
How long we will keep your information
The information that you supply to us will be kept on file by for
3 years after the child leaves the setting, at which point it will be disposed of securely. Information
shared with the local authority will be retained for 25 years after its creation, at which point it will
also be disposed of securely.
What are your rights?
will be the Data Controller for this information.
You have the following rights in relation to this data.
• You have the right to be informed about what information we hold about you and how we use
it.
• You have the right to request copies of any information we hold about you by making a subject
access request.
• If information we hold about you is factually inaccurate you have the right to have it corrected.
• You have the right to object to the way we are using your data.
• You have the right to request that your data is deleted. However we may be unable to delete
your data if there is a need for us to keep it. In this case you will receive an explanation of why
we need to keep the data.
• You can also request that we stop using your data while we consider a request to have it
corrected or deleted. There may be some circumstances in which we are unable to do this
however we will provide an explanation if this is the case.
• In certain circumstances you may also request data we hold about you in a format that allows it
to be transferred to another organisation.
• In the event that decisions are taken using automated processes you have the right to request
that these decisions are reviewed by a member of staff and to challenge these decisions.
If you would like to request copies of your data, request that your data is deleted or have any other
queries in relation to data which holds about you
please contact
If you are unhappy with the way that has used your
data or with the way we have responded to a request you also have the right to contact the
Information Commissioner’s Office www.ico.org.uk .
Clarification for eligibility funding
As detailed in the Childcare Act (2006), childminders are not able to claim funding for their own
children, grandchildren or for any member of their family through blood or marriage. This will be
actively monitored by Hertfordshire County Council and if there is enough evidence to confirm
that funding has been claimed contrary to these regulations, it will be refused and reclaimed if
necessary.
[Provider name]
[Provider name]
[Provider name]
[Provider name]
I I I I I I I I
Parent declaration form – free early education and childcare for two, three and four year olds
Section A – Family Information
Your child is entitled to 570 hours free early education per year which they can access with a nursery
school/class, pre-school, day nursery or childminder. The free early education hours can be split
between two providers as long as both agree to the split. The number of hours accessed must not
exceed the total allowed in that funding period. If your child is three or four you may be able to
access an additional 570 hours of free childcare (known as 30 hours free childcare); eligibility criteria
apply. If you are eligible the total of 1140 hours may be split over a maximum of three providers on a
maximum of two sites per day.
Child Details (main) Boxes marked with a * are mandatory.
First name*
Middle name(s)
Surname*
Gender*
Date of birth (DoB)*
National Health number (NHS
No.) (must start with 6 or 7)*
Ethnicity*
Address*
(with postcode)
SEN provision
(please tick one)
Education Health &
Care Plan (EHCP)
SEN Support
None
Child Details (additional)
Two year old funding code
(if applicable)
/
The following are only required if accessing a 3 & 4 year old place or 30 hours free childcare
30 hours free childcare
voucher code (if applicable)
Early Years Pupil Premium
(EYPP) extended criteria
(please only tick one if
applicable)
Child adopted
Child Arrangement
Order
Child Looked After (i.e.
in Foster Care)
Special Guardianship
Order
In receipt of disability living
allowance (DLA)
YES
NO
DLA form reference No.
DLA form expiry date
3
__________________________________________
Parent declaration form – free early education and childcare for two, three and four year olds
Parent / Carer Details
This information is required to confirm eligibility for Early Years Pupil Premium (EYPP) and 30 hours
free childcare entitlement.
First Parent/Carer
Second Parent/Carer
First name
Surname
Date of birth (DoB)
National Insurance Number
(NI No.) e.g. AB123456C
National Asylum Support
Service (NASS) number
(YYMMNNNNN)
Section B – Provider Information
Provider 1
Name:
_____________________________________
No. free hours
attended per week:
_______
Contact number:
_____________________________________
Provider signature:
_____________________________________
Date:
Provider 2
Name:
_____________________________________
No. free hours
attended per week:
_______
Contact number:
_____________________________________
Provider signature:
_____________________________________
Date:
Only complete details for Provider 3 below if you are accessing any additional hours of free childcare in
the 30 hours free childcare scheme across more than 2 providers.
Provider 3
Name:
_____________________________________
No. free hours
attended per week:
_______
Contact number:
_____________________________________
Provider signature:
_____________________________________
Date:
30 hours free childcare declaration
If your child is splitting their 30 hours free childcare entitlement across two or more providers
please nominate the main provider where the local authority should pay the first 15 hours to
4
_______
I I
I I
I I
__________________________________________
Parent declaration form – free early education and childcare for two, three and four year olds
Disability Access Fund declaration
If your child is eligible for the Disability Access Fund (DAF) and is splitting their free entitlement
across two or more providers please nominate the main provider where the local authority
should pay the DAF to (if your child changes provider in the year the funding will remain with
the provider you have selected below).
Section C - Parent declaration - to be signed by parent/carer once each year unless changes occur
Please complete this section with your provider
Summer funding period (1 April – 31 August) – Indicate if stretched offer applies
Yes
No
Funding Period
2 Year old
3 & 4 Year old
30 hours free childcare
Start Date
No. of days per week
Total hours per week
Total free hours per week
(max 15 per scheme)
No. of weeks (e.g. 13 for term time)
Autumn funding period (1 September – 31 December) – Indicate if stretched offer applies
Yes
No
Funding Period
2 Year old
3 & 4 Year old
30 hours free childcare
Start Date
No. of days per week
Total hours per week
Total free hours per week
(max 15 per scheme)
No. of weeks (e.g. 14 for term time)
Spring funding period (1 January – 31 March) – Indicate if stretched offer applies
Yes
No
Funding Period
2 Year old
3 & 4 Year old
30 hours free childcare
Start Date
No. of days per week
Total hours per week
Total free hours per week
(max 15 per scheme)
No. of weeks (e.g. 11 for term time)
5
Parent/carer declaration
I confirm that my child _____________________________________________is attending the early years
provider(s) for the free hours detailed above.
I understand how the free early education hours will be delivered for my child. If my child is receiving a
stretched offer and reverts to the term time offer, the number of free hours available each week may be
affected.
I will make every effort to ensure my child attends the free hours claimed for. I am aware that to continue
receiving 30 hours free childcare, that I need to recheck my voucher code every 3 months as a minimum
(by the end of each funding period to ensure it remains valid for the following period).
Name* :
Date:
Signature*:
Parent declaration form – free early education and childcare for two, three and four year olds
Any changes to the declaration must be noted below and signed by the parent/carer during the year
Name* :
Date:
Signature*:
Name* :
Date:
Signature*:
Name* :
Date:
Signature*:
6
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Completed 10 February 2021

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