EARLY YEARS INCLUSION FUNDING - CONTINUATION of APPLICATION FORM: Part 1: Key Information

Name of Child: / Date of birth: / Date of Initial Application:
Age in Years & months: / Diagnosis: – NHS/Private
Parent/carers: / Address:
Post Code:
Telephone:
Provider: / Address:
Post Code:
Telephone:
National Curriculum Year Group NCY / Pre School/FS1 / FS2 / E-CAF / YES (indicate reason) NO
Is the child/young person a member of a vulnerable group? / Was/is this child a funded 2yr old?
YES/NO / GRT family: YES/NO / EAL: YES/NO Language/s spoken / Pupil Premium
YES/NO / HM Armed Forces:
YES/NO
Child In Care / YES/NO / Borough with parental responsibility of CIC
Start date/proposed start date at provider
If child is unable to start without additional support please attach supporting evidence
Name of Social Worker (if applicable)
Name of Early Years Manager/Supervisor and contact details
Name of Early Years SENCo and contact details
Please indicate how many funded hours are attended each day / Monday / Tuesday / Wednesday / Thursday / Friday
Attendance: No.of funded session attended last term / No. of funded session actually attended last term
Name and address of any other provider attended
Please indicate how many funded hours are attended each day / Monday / Tuesday / Wednesday / Thursday / Friday
Attendance: No. of funded session attended last term / No. of funded session actually attended last term
Future Schooling: Please complete this box if child is due to go to school in the next academic year as a 4 or 5 year old
Name of school being considered for statutory age schooling i.e. term following 5th birthday / Considering Deferral / YES/NO
Proposed start date at above school. (This maybe before age 5)
Part 2: Supporting Attainment Information: Please attach the updated Early Years Developmental Journal Grid/s
Additional Supporting Information – Prime/Specific
If you have completed the EYDJ for more than a term but the steps on the grid do not show measurable ‘achievement’ in the 3rd column, please detail any ‘emerging’ and ‘developing’ skills as per the example below, in all areas relevant to the either the ‘Prime’ or ‘Specific’ journal
FOR EXAMPLE:
In PSED xxxxx is demonstrating emergence of some aspects of step 8 – quote ‘Can tolerate brief separation from special people’.

‘Continuation’ application - please attach a copy of the updated Early Years Developmental Journal Grid only

Current Provision Map; What is currently being provided to meet the child’s needs?
Area of Need / Strategies/Resources /Interventions/Aids/Adaptations already in place / Date that these interventions/ strategies started / Named individual supporting child/enhancing ratio? / Frequency of intervention i.e. ½ hr each day/session or % / Outcome: What will the child be able to do as a result of these interventions?
Xxxxx will be able to ……………
1.
Communication and interaction
2.
Cognition and learning
3.
Social, emotional and mental health
4.
Sensory and/or physical needs
Detail any changes from previous applications, (e.g. professionals involved, needs) and any further assessments being waited for:
IMPACT OF FUNDING ON CHILD’S PROGRESS
What impact has the EY Inclusion funding (EYIF) had in terms of expected progress specifically in the areas of need previously identified ?
How will further EY Inclusion funding (EYIF) be used to support the child and ensure continued progress?
What will the child be able to do as a result of FUTURE interventions?
Name of member of staff who will be released to offer support over and above normal staff ratio?
For what proportion of the free entitlement funded session will the staff member be supporting? (3 hr session)
In the rare circumstances it’s considered necessary to purchase specialist toys/play resources, supply detailed evidence of why needed, cost and supplier. Include picture of resource.

PARENTAL REVIEW DOCUMENT MUST BE ATTACHED; APPLICATIONS WILL NOT BE CONSIDERED IF MISSING!


Parental/Guardian Consent statement for information storage and information sharing

You are asked to consent to personal information about you and this child being shared with other organisations and agencies where it is appropriate to do so. Information: obtained during an assessment; any subsequent use; and any information already held; may be shared with others directly involved in caring this child.

The purpose of sharing information is to ensure suitable services are provided, through a better understanding of the individual’s strengths and needs. Access to the information will only be given to staff that have a reason to see it. Information can be shared without permission where there might be a child at risk of harm or has been harmed, or where a serious crime has or may be committed. Your information is protected by the Data Protection Act 1998. The information will, therefore, only be used for the reasons stated. It will be kept safe and secure. You have the right to see the information that is being kept about this child.

I give my consent for information about this child to be shared with any appropriate agency in order to help this child receive a better service. I understand that by signing this form, it does not affect my rights under the Data Protection or Human Rights law. I understand that at any time I can change or withdraw my consent by notifying the person who has completed this application.

Child’s
Surname / Given names / Date of Birth / Gender
Address / NHS Number
Ethnicity / Language/s spoken at home / Religion
Parent/Guardian Signature/s / Print name / Date:
Print name / Date:
Signature Manager//Head/Supervisor / Print name / Date:
SENCo
Signature / Print name / Date:

Exceptional circumstances: concerns about significant harm to infant, child or young person

If at any time during the course of this assessment you are concerned that an infant, child or young person has been harmed or abused, or is at risk of being harmed or abused, you must follow your Local Safeguarding Children Board (LSCB) safeguarding children procedures. The practice guidance What to do if you’re worried a child is being abused (HM Government, 2006) sets out the processes to be followed by all practitioners. If you think that the child may be a child in need (under section 17 of the Children Act 1989) then you should also consider referring the child to children’s social care. These referral processes will be included in your local safeguarding children procedures and are set out in Chapter 5 of Working Together to Safeguard Children (2006). (www.ecm.gov.uk/workingtogether). You should seek the agreement of the child and family before making such a referral unless to do so would place the child at increased risk of significant harm.

Provider to complete the top half of this page.

Name of Child / Name of Setting:
Checklist for attachments
Early Years Developmental Grid/s / Early Years Intervention Plan (EYIP)
Language Tracker / Parental consent form signed
Parental /Carer Feedback Form
Applications will not be considered if this not attached
Applications submitted or received after the submission date will not be accepted or considered under any circumstances.
Incomplete application may be declined
Please return completed applications to
Julie Sargeant
Early Years /Children’s Services
Wokingham Borough Council
Shute End
Wokingham RG40 1BN
For office use only
Date received: / Panel members:
HH SG KH CB AP
SS MW SB
Panel Meeting date
EYIF additional support / Agreed/ Declined / Amount agreed:
Number of academic terms:
Comments and/ conditions of award including reasons for declining
Authorised Signature for the Early Year Childcare and Play
Service /
Date:

RESTRICTED EYIF CONTINUATION APPLICATION Jul 2016 V7 Page 2 of 7