Nursery Application and Declaration Form

I confirm I have read the privacy statement in full and that a copy has been made available to me on request. This includes why we need your family information, what we will do with it, how long we will keep it, what are your rights, clarification on eligibility and using your Childcare Support hours. By completing this parent declaration form, I am agreeing to the privacy notice; https://www.hertfordshire.gov.uk

Boxes marked with a * are mandatory

Legal Name of Child

First NameMiddle NameLast Name

Preferred First Name if Different

Gender of Child

Date of Birth of Child

DayMonthYear

National Health Number (NHS) of Child

10 digits

Ethnicity of Child

Home Language of Child

Religion of Child

Address of Child - evidence of address will be required if the Nursery is oversubscribed. This would be either a utlities bill (gas, electric or water) or a council tax bill/statement.

Street Address

Street Address Line 2

Town

Post Code

Early Years Pupil Premium (EYPP) extended criteria (please only tick if applicable)

Is the child in receipt of Disability Living Allowance?

DLA form reference number

.Format: 0000 00000.

DLA form start date (dd/mm/yyyy)

DayMonthYear

DLA form expiry date (dd/mm/yyyy)

DayMonthYear

This allows the early years provider to claim Disability Access Fund (DAF) which supports your child to access their childcare. DAF can only be claimed by one provider.

Name of Early Years setting / Preschool your child attends or has attended

e.g. Sunbeams, childminder, none etc

Special Education Needs - Does your child have a Statement of Special Educational Needs or an Educational Health and Care Plan (EHCP) ? If 'yes' please provide evidence.

At risk - Is your child, or a sibling of your child, subject of an inter-agency child protection plan and been placed on the Child Protection Register ? If 'yes' please provide evidence.

Social or Medical Reasons - Do you have a particular medical or social need to go to this school that another school cannot provide ? If 'yes' please provide evidence.

Does a sibling attend Broom Barns Primary School

Sibling's Name

First NameLast Name

Other Relevant Information e.g. medical conditions, allergies, dietary etc.

Asthma, hayfever, nut allergy, vegetarian etc.

Full Name of Parent / Carer Living With the Child (priority 1)

Title (Mr/Mrs/Miss)First NameMiddle NameLast Name

Date of Birth of Parent

DayMonthYear

Relationship to Child

Mother, Father, Grandparent, Carer etc

National Insurance Number of priority 1

9 digits

Mobile Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Home Phone Number

Please enter a valid phone number.Format: 00000 000000.

Work Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Email for Priority 1

example@example.com

Second Parent?

Full Name of Parent / Carer (priority 2)

Title (Mr/Mrs/Miss)First NameMiddle NameLast Name

Date of Birth of Parent/Carer 2

DayMonthYear

Relationship to Child

Mother, Father, Grandparent, Carer etc

National Insurance Number of priority 2

9 digits

Mobile Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Home Phone Number

Please enter a valid phone number.Format: 00000 000000.

Work Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Email for Priority 2

example@example.com

Address of Priority 2 Parent/Carer

Street Address

Street Address Line 2

Town

Post Code

Full Name of Emergency Contact (priority 2)

Title (Mr/Mrs/Miss)First NameMiddle NameLast Name

Relationship to Child

Mother, Father, Grandparent, Carer etc

Mobile Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Home Phone Number

Please enter a valid phone number.Format: 00000 000000.

Work Phone Number

Please enter a valid phone number.Format: 000 000 00000.

Address of Priority 2 Emergency contact

Street Address

Street Address Line 2

Town

Post Code

DECLARATION

The information I have given on this form is complete and accurate. I understand that my personal information will be held securely and will be used only for local authority purposes.

I agree to Broom Barns School using this information to consider my application for a nursery place. I understand that if any part of this completed application for is found false the offer of a place will be withdrawn.

I understand that the completion of an application does not guarantee a place in nursery class.

I understand that, if offered a place in the nursery class, I have to apply separately for a place in reception (Primary).

I understand I must provide evidence at the time of application if I have answered ‘YES’ to any of the criteria overleaf e.g. SEN, Medical reasons etc.

I agree to complete, in full, and return a Nursery Declaration Form if my child is offered a place at Broom Barns Nursery.

DATA PROTECTION
In accordance with General Data Protection Regulation and current Data Protection Act, the school has a duty to protect this information and to keep it up to date. The school is required to share some of the data with the Local Authority and with the DfE.

Privacy Notice
In completing this application form you should refer to our Privacy Notice for Parents/Carers. The personal information collected on this form will be processed to manage your application in accordance with our Data Protection Policy.

Privacy notice

I understand and I authorise Broom Barns Primary School to claim free entitlement funding as agreed on behalf of my child and give my consent. (This information is used to apply for funding on Hertfordshire Funding Database when your child becomes eligible).

I have read and agree with our Parent Privacy Notice.

I confirm that the details above are correct to the best of my knowledge.

Signature

Nursery Application and Declaration Form

Child's Details

Parent / Carer Details and Emergency Contact Details

Emergency Contact Details (priority 2)