PARENTAL AGREEMENT: Funded Early Years Provision for 2, 3 & 4 Year Olds
All parents of eligible 2, 3 and 4 year olds must complete a Parental Agreement for each Early Years childcare provider their child attends. This allows the provider(s) to be paid for the Early Years funded entitlement of 15 hours or 30 hours per week. To allow your child's provider to claim for these funded hours and, where applicable, Early Years Pupil Premium you will need to provide your date of birth and your national insurance number/NASS.
Name of Childcare Provider:
*
Section 1: Child Details
Child's Legal Forename:
*
Child's Middle Name:
Child's Legal Surname:
*
Child's Preferred Name:
Child's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Date of Birth:
*
-
Month
-
Day
Year
Date
Child's Gender:
Male
Female
Other
Prefer not to say
Child's SEN Stage:
Ethnic Background:
*
White British
White Irish
White Traveller of Irish Heritage
White Gypsy/Roma
Any Other White Background
Black Caribbean
Black African
Any Other Black Background
Indian
Pakistani
Bangladeshi
Any Other Asian Background
Chinese
Mixed White & Black Caribbean
Mixed White & Black African
Mixed White & Asian
Any Other Mixed Background
Any Other Ethnic Background
I do not wish an ethnic background to be recorded
Is your child eligible and in receipt of Disability Living Allowance?
Yes
No
If YES, please nominate the early years provider that you wish to claim for the Disability Funding Allowance:
Name of nominated childcare provider
Section 2: Weekly Attendance & Claim Details
Enter the hours that your child will be attending THIS childcare provider:
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Universal Funded Hours (up to 15 per week)
Extended Funded Hours (up to 30 per week) if eligible
Non-Funded Hours (paid for by parent)
Enter the hours that your child will be attending a DIFFERENT childcare provider (if applicable):
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
Universal Funded Hours (up to 15 per week)
Extended Funded Hours (up to 30 per week) if eligible
Non-Funded Hours (paid for by parent)
Name of the other Childcare Provider (if applicable):
Section 3: Parents/Carers with Parental Responsibility
The sections below must be completed to enable Stepping Stones Nursery & Out of School Club to check and claim (if applicable) for the correct number and type of funded hours.
Parent/Carer 1 Full Name:
*
First Name
Last Name
Parent/Carer 1 Date of Birth:
*
-
Month
-
Day
Year
Date
Parent/Carer 1 National Insurance Number:
*
Parent/Carer 1 NASS Number:
Parent/Carer 2 Full Name:
*
First Name
Last Name
Parent/Carer 2 Date of Birth:
*
-
Month
-
Day
Year
Date
Parent/Carer 2 National Insurance Number:
*
Parent/Carer 2 NASS Number:
Child's 30 Hours Eligibility Code:
Child's 2 Year Old Voucher Code:
Section 4: Parental Declaration
Please tick to
YES
I confirm that the details stated on this form are correct.
I accept that i must discuss any change in my child's funded hours during a term with all Early Years providers that my child attends.
I understand that I cannot claim my entitlement across more than two providers in one day.
I understand that I cannot claim more than the weekly maximum of up to 30 funded hours (if eligible).
I authorise the named provider on this form to validate the 30-hour eligibility code if provided.
I understand that if I cease to meet the 30-hour eligibility criteria, I will continue to receive extended entitlement for the 'grace period' only at my current provider.
I authorise North Yorkshire County Council to exchange information I have provided with my child's childcare providers, other local authorities (if my address is outside of North Yorkshire), and the Department for Education.
I authorise North Yorkshire County Council to exchange information about my child's take up of the entitlement.
I authorise North Yorkshire County Council to check my eligibility for Early Years Pupil Premium enabling the appropriate funding to be paid to my Early Years provider based on Universal hours only.
I understand that Early Years providers and the Local Authority are bound by the Data Protection Act and will not reveal information held on my child to a third party unless the law allows us to.
I confirm that I have read, and agree to, all of the points in the declaration above.
Please upload photo evidence of your child's date of birth:
Browse Files
Attach a photo of your child's birth certificate, passport, or other form of evidence
Cancel
of
Parent/Carer Name:
First Name
Last Name
Parent/Carer Signature:
Clear
Date of Signature:
-
Month
-
Day
Year
Date
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm