Free Childcare for 2 year olds

Free Child Care

Please complete the details below to find out if your 2 year old child is eligible. Please only use full legal names when completing this form, including middle names

* Denotes mandatory info that must be provided in order to process the application

Applicant's details: (Person in receipt of qualifying benefits/entitlements)
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(Or National Asylum Support Service (NASS reference number))
Yes No

As Parents/Carers, are you on any of the following benefits/entitlements?
Income Support
Income-based Jobseeker's Allowance
Income-related Employment and Support Allowance
Support under Part 6 of the Immigration and Asylum Act 1999
Guarantee Element of State Pension Credit
Child Tax Credit and/or Working tax credit and have an annual income not exceeding £16,190 as assessed by Her Majesty’s Revenue and Customs.

And/or does your two year old match any of the following criteria?

Please tick all that apply

Child is Adopted
Name of Social Worker
Child is a Looked After Child (LAC) e.g. in Foster Care
Name of Social Worker
Child has left care through a special guardianship or residence order
Name of Social Worker
Child has a statement of special educational needs (SEN) or an education, health and care plan.
Child gets Disability Living Allowance (DLA) in their own right.
2 Year Old Child's details:
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Male Female
Yes No
Siblings:
Are you registered with a Sure Start Children's Centre? Yes No
Are there any professionals involved with your family at the moment?
Health Visitor: Please give name if known:
Portage Worker: Please give name if known:
Social Worker: Please give name if known:
Children's Care Worker: Please give name if known:
Family Support Worker: Please give name if known:
Other: Please give name if known:

Please state if there is a particular childcare provider that you would like to use, subject to a place being available:
Transport
If no childcare is available in walking distance, are you able to transport your child to the provider? Yes No
Declaration
I certify that the information given on this form is complete and accurate, to the best of my knowledge and belief. I understand that the council will use this information to confirm receipt of one of the listed welfare benefits or entitlements by checking benefit and tax credits data provided by HMRC and DWP. I also agree to the local authority using this information to enable my child’s School/Nursery/ Playgroup / Childminder to claim the early years pupil premium (EYPP) for my child when they later commence their 3 & 4 year old funded early education place.

I understand that the personal information I have provided is held securely and may be used and shared for local authority purposes e.g. with Sure Start, that could offer further support to my family, and also with potential childcare providers.

Parent/Carer: I confirm that I have read the declaration and agree to the terms and conditions outlined. *

Professional: If you are a professional completing this application on behalf of a parent, please provide your details below and confirm that you have explained the terms and conditions in the declaration above to the parent concerned: *

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Where did you hear about this?


Provider Use only
Childcare Provider to type in golden ticket number here (if applicable):

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