REQUEST FOR DISCRETIONARY FUNDING FOR EARLY YEARS SETTINGS

Section 1
Surname: / Male/Female:
Also known as: / Date of Birth:
Forename(s): / Date of admission to Early Years Setting/School:
Home address:
Postcode:
Is this a Looked After Child? Yes/No

Name of Parent / Carer with day-to-day responsibility for the child:

Mr / Mrs / Miss / Other / Surname:
Forename/s: / Relationship to Child:
Telephone (Home):
Telephone (Work) / Email:
Home Language: / Religion:
Please detail any special arrangements needed when communicating with parent/carer:

Name of other adults with responsibility for the child:

Mr / Mrs / Miss / Other / Surname:
Forename/s: / Relationship to Child:
Home address (if different to above)
Postcode: / Telephone (Home):
Telephone (Work)
Email:

Early Years Setting / School:

Setting Name:
Maintained/non-maintained:
Telephone:
Email: / Address:
Postcode:
Entitlement, tick appropriate box
Universal (540 hours) o
Extended (1140 hours) o / If eligible for extended entitlement enter 11 digit code below.
______
Funded hours per week attended
Weeks per year attended.
Number of children in group and attendance ratio:
All children with SEND Support Arrangements should be working towards agreed outcomes. Please show give the reasons why discretionary SEN funding is required to support progress towards outcomes and explain how this additional support would be used:

Section 4 Evidence Needed

Prior to requesting discretionary funding settings should have followed a graduated approach as set out in the SEND Code of Practice
Please attach (tick box to show attachments)
SEND Support Arrangements
Relevant professional reports issued within the last 6 months
[Please list additional reports attached]
Manager of Early Years Setting
I believe that this child may need additional support beyond that which is available within the local offer.
I have sought advice from the Supporting Children Team and my SEND Advisor is aware that I am making this request.
I confirm that the entitlement eligibility has been checked and will continue to be regularly checked in line with the guidance.
Name:
Signed:………………………………………….
Designation:
Date:
Parent / Carer
I agree with this request for discretionary funding being made by the nursery and that information about my child will be shared with those professionals who are involved considering the request
Parent / Carer’s Name
Signature(s):…………………………………… Date:

Please securely email completed form and attachments to:

South West:

North West:

South East:

North East:

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