PARENTAL AGREEMENT: Funded Early Years Provision for 2, 3 & 4 Year Olds

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:
Child's SEN Stage:
Ethnic Background: *
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 at STEPPING STONES:

	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 at 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
Should be Empty:

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Section 1: Child Details