Childcare Support Fund REFERRAL Application Form

Childcare Support Fund REFERRAL Application

Care and Learning Alliance (CALA)
Section 1: About You
This form should be completed by a professional referrer on behalf of a parent/carer seeking flexible, short-term childcare support. Please complete it with the parent/carer’s informed consent. All information will be treated confidentially.
Section 1: Applicant Details
Referrers Name:

First NameLast Name
Organisation and job title
Professional Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Relationship to family
Preferred Method of Contact:
Section 2: Parent/Carer Details
Parent/Carer name (responsible for payment of childcare fees):

First NameLast Name
Please provide any further relevant information: (for example if childcare costs are split across parent/carer)
Address of parent applying for funding

Street Address

Street Address Line 2

City

Postal / Zip Code
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Section 3: Child(ren's) Details

Please provide details of children requiring childcare support:

Rows	Child's Name	Date of Birth	Are you accessing funded hours. If yes please state number of hours per week	Please state if the childcare is term time only or all year round.
1
2
3
4
5

Please provide us with any relevant further information regarding the child(ren) e.g Additional Support Needs:
Section 4: Household Information
Number of adults in the household:
Number of dependent children:
Is the family paying for childcare or additional hours above funding element?
How many hours?
Please select which applies
Please advise of any other relevant information

Section 7: Temporary Financial Hardship
Have the household circumstances changed unexpectedly within the last 12 months?
If yes, please describe what has happened and how it has affected their household income or ability to pay for childcare.

Examples may include:
• Illness or disability
• Bereavement
• Loss of employment
• Reduction in working hours
• Family breakdown
• Unexpected caring responsibilities
• Other unforeseen circumstances
Has this change resulted in a temporary loss or reduction of household income?
If yes, please estimate the monthly reduction in income:
Are circumstances expected to improve within the next 12 months?

Section 10: Declaration
I confirm that I consent to the named professional referrer submitting this referral and application on my behalf.

I authorise the sharing of the personal and household information in this form with CALA for assessment, administration, monitoring and evaluation of the Childcare Support Fund.

I understand that CALA may contact me and/or the referrer to verify the information provided, and I confirm that the information about me and my family is accurate to the best of my knowledge.

I also fully understand it is my responsibility to ensure that making a claim through the Childcare Fund will not affect any other financial support, benefits, or assistance I currently receive. This may include, but is not limited to, Universal Credit, Tax Credits, Housing Benefit, Council Tax Reduction, or other means-tested benefits.

CALA recommend that you seek advice from your Work Coach or contact the relevant benefit provider if you are unsure how a claim may impact your entitlement. Click here if you are unsure how to contact your Work Coach.
By signing this document below, you confirm that you have read, understood and agree to the statements above.
Parent/Carer Name:

Referrers NameLast Name
Parent/Carer Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Section 11: Professional Referrer Declaration
I confirm that I am submitting this application on behalf of the parent/carer named within this form and that I have obtained their informed consent to do so. The parent/carer has authorised me to share the information contained within this referral for the purpose of assessing eligibility for the Childcare Support Fund and administering any award. To the best of my knowledge, the information provided is accurate and complete. I understand that CALA may contact me and/or the parent/carer to verify the information and may process personal data in accordance with applicable data protection legislation.
Referrers Name

First NameLast Name
Referrers Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Supporting Information
Supporting information may include a Universal Credit award notice, an employer’s letter, medical evidence, evidence of bereavement or changed family circumstances, or confirmation of training or education. Lack of evidence will not automatically prevent consideration where obtaining it would cause hardship.
Should be Empty:

Childcare Support Fund REFERRAL Application

Section 1: About You

Section 1: Applicant Details

Section 2: Parent/Carer Details

Section 3: Child(ren's) Details

Section 4: Household Information

Section 5: Reason for Referral and Current Circumstances of the Family

Section 6: Financial Support and Benefits

Other Childcare Support

Section 7: Temporary Financial Hardship

Household Income

Impact on Family

Section 8: Childcare Support Requested

Section 9: Outcomes

Section 10: Declaration

Section 11: Professional Referrer Declaration

Supporting Information