***Restricted***

PART A

SECTION 1
(i) Child’s Surname: Forename(s):
DOB: School Reception Start Date:
Home address:
Postcode:
Looked After: Yes No Not sure Home LA:
(ii)  Please provide a brief description of the child’s needs including any diagnosis:
(iv) How many hours does the child attend at your setting:
SECTION 2
Name of Pre-school setting: URN/PVI Setting code:
Number in room/group:
Form completed by: Designation:
Telephone no: Fax: E-mail:
District: Date of EYrs Forum meeting:
(Please ensure completed application is received by the Business Support Team in the appropriate district office at least 10 working days before this date, addresses at the end of the form. Incomplete forms will be returned)
SECTION 3 External agencies currently involved:
Educational Psychologist Behaviour Support Early Years Area SENCO
Hearing or Visual Impairment Autism Outreach Team Paediatrician Speech and
Language Therapist Physiotherapist Occupational Therapist Social Care
Physical Disability Support Service LST Child and Family Engagement Worker
CAMHS Midlands Psychology
Any other agency (please specify)

PART B

Existing Resources

Basic SEN Information:

primary need
secondary need

(For primary/secondary need choose from: SEMH (social emotional and mental health needs), CLN (cognition and learning needs), CIN (communication and interaction needs), S/PN (sensory and/or physical needs))

What additional support are you already providing?

Type of additional support / Size of group / How often and how long / Who is supporting?
Total hours per week, 1:1
Total hours per week, small group
Total hours per week, whole group

PART C

Child’s current skills

Chronological age:

Please provide information about the child’s current developmental levels across all areas of development using the EYFS and/or any other assessment or recording tool
Are there any other relevant factors which may impact on the child’s learning, development and progress, e.g. attendance, illness, changes in family or setting circumstances?

PART D

Proposed use of ADN Resources

Please indicate below how additional resources would be used.

Funding is up to a maximum of 15 hours/week (unless eligible for 30 hours).

Targeted area to be developed and supported.
(Please give as much detail as possible.) / 1 : 1 / small group/
whole group / Number of hours per week / Number of weeks if short-term need
Total hours
Warning Note:
ADN funding awarded is subject to scrutiny and monitoring at any time.
If awarded funding is not being used to support the individual pupil for whom it was given as agreed, then funding will be withdrawn retrospectively and with immediate effect.

PART E

Criteria

Funding levels are based on Staffordshire’s graduated response, including the criteria. Please indicate which criteria and level of need best fits this child:

Additional needs / Complex needs / Severe needs
Two-year-old criteria
Three-year-old criteria
Visual Impairment criteria
Hearing Impairment criteria

Please attach a copy of the criteria to this application form, underlining the statements that refer to the child (please ensure that this will photocopy successfully).

PART F

Checklist of Evidence

þ  Please tick boxes, as appropriate, to show the evidence used in the completion of this application. Please attach this evidence with your application.

The levels of the criteria reflect an increase in frequency, duration and intensity and it is essential that evidence reflects this. Judgements must be age appropriate and made in relation to National and County norms, rather than those that might apply in a particular setting.

Please attach these

IEPs/evidence of support in targeted areas

Development journal summary sheet (or similar summary of skills)

Personal Education Plan if pupil is Looked After

Please send forms to the appropriate district office. Forms needs to be received at least 10 working days before the forum to be considered at the first available forum.

Setting SENCo:

Signature:

Name (please print clearly)

Date

- 1 -

September 2017

- 1 -

September 2017

Stafford and South Staffs:

Business Support Team

The Kingston Centre

Fairway

Stafford

ST16 3TW

Lichfield and Cannock:

Business Support Team

The Old Library

Bird Street

Lichfield

WS13 6PN


Newcastle and Moorlands:

Business support Team

Seabridge Centre

Ashway,

off Seabridge Lane,

Newcastle,

ST5 3UB

East Staffs and Tamworth:

Business Support Team

Burton Education Centre
Grange Street
Burton-on-Trent

DE14 2ER

- 1 -

September 2017

- 1 -

September 2017