About the Child

Childcare Inclusion Fund 2017 - 2018

NEW APPLICANT

Summer Half Term 29th May – 2nd June 2017

Please refer to the Childcare Inclusion Fund Information for Parents and Childcare Providers when completing this form.

If you have any questions about this form or the funding, please contact Jenny Perrin on (01273) 293670.

Section one: about you and your child

Your child’s name:………………………………………..Date of birth:…………………………..

Your name:………………………………………………..Telephone number:…………………..

Address:………………………………………………………………………………………………

Your child’s school:………………………………………………………………………………….

Your child’s SENCO/key worker:…………………………………………………………………..

Is your child attending childcare while you are working or training? (please tick box)

YesNo

If yes, hours you work:

Monday / Tuesday / Wednesday / Thursday / Friday

From:

To:

Is your child attending childcare while your partner is working or training? (please tick box)

YesNoNot applicable (single parent)

If yes, the hours your partner works:

Monday / Tuesday / Wednesday / Thursday / Friday

From:

To:

Section two: the support that your child needs

Does your child have an Education Health Care Plan (EHCP)

or Statement? YesNo

Does your child have additional support at school? YesNo

Has an Early Help Assessment (EHA) or

Common Assessment (CAF) been carried out? YesNo

Does your child receive Disability Living Allowance (DLA)  YesNo

If a child does not have one or more of the above but it is felt by the parent and provider that additional support is needed EYC will consider the application and make an onsite assessment.

Please identify your child’s special needs:

Autistic spectrum disorder (ASD)

Physical disability

Multi-sensory impairment

Visual impairment

Hearing impairment

Speech and language and communication needs

Behaviour, emotional and social difficulties

Profound and multiple learning difficulties

Complex medical needs

Chronic conditions such as asthma, eczema or diabetes

Moderate learning difficulties

Not diagnosed

Unclassified

Other

Please briefly explain the type of support your child needs e.g. toileting, eating, keeping safe.

…………………………………………………………………………………………………………

Does your child need help communicating with other people?

…………………………………………………………………………………………………………

What support or encouragement does your child need to get the most out of play?

…………………………………………………………………………………………………………

Section three: Other agencies involved in supporting your child

CAMHSPreSENS

Children’s Disability Team (Seaside View)Young Carers

Social ServicesSpeech and Language therapy

Other (please state)……………………………………………………………………………….

Do you receive…

DLA (Disability Living Allowance)Yes No

Direct PaymentsYes No

The childcare element of Working Tax Credit Yes No

Any other contribution towards the cost of childcare (please state)

………………………………………………………………………………………………………..

Please indicate your main reasons for using childcare provision:

I workIt offers me a short break 

I’m training/ attending collegeIt is a play opportunity for my child

Anything else you would like to add:

…………………………………………………………………………………………………………

Please sign and date this application

Your signature:………………………………………………………………..Date………………..

Thank you for completing this form. Please pass it back to your childcare provider.

To be completed by the childcare provider

Name and address of childcaresetting…………………………………………………………..

……………..………………………………………………………………………………………….

Contact name ………………………………………..Contact number…………………………..

Contact e-mail……………………………………………………………………………………….

Holiday Club: Child’s weekly attendance (please complete start – finish times)
Day / Monday / Tuesday / Wednesday / Thursday / Friday
Times
Total hours per week and weeks in holiday
Expected start date

How will the inclusion funding be used? (please tick)

Worker time Equipment Training other

What is the hourly rate for the worker?£…………………..p/h

(A maximum of £10.00 per hour will be paid towards staff costs)

Total cost for the worker: £…………………………

Details/breakdown of how grant will be used.
Total amount requested / £

If there is a shortfall please indicate how you plan to meet this………………………………...

…………………………………………………………………………………………………………

Have you identified a worker to provide support for this child? Yes No

What is their qualification level and experience of working with children with special needs?

…………………………………………………………………………………………………………

Have any training needs been identified to support this child’s inclusion?

………………………………………………………………………………………………………....

…………………………………………………………………………………………………………

What other changes will be made to make sure that the whole team supports this child’s inclusion?

…………………………………………………………………………………………………………

Is the child benefitting from an affordable childcare place?Yes No

Are there any other funds being used to pay for the fees? If yes, please give details:

…………………………………………………………………………………………………………

Please sign and date this form.

Your signature………………………………………………………Date………………………….

Thank you for completing this form. Please return it to: