Free TwoYearOld Childcare PlaceReferral Form

It is essential to complete all sections of the form and add supporting details as requested, focusing on the child’s needs. Incomplete details will result in form being returned to referrer.

Full Name of Child / Date of Birth / Gender
Mothers Name / Fathers Name
NI Number / DOB / NI Number / DOB
Do either of the parents have English as an additional language? Mother Father
Family Address
Postcode / Has the child had their 2 year development check?

Yes No
Telephone
Does the child/family have access to transport?
Yes No / Was the birth of the child premature? yes no
If yes, by how many weeks?
Is the child/family living in temporary accommodation? Yes No
Including the twoyearold, how many children in the home are under 5 years of age?
Total Number of 0-19 year olds that are living in the family home?
What School do any siblings attend?
CHILD DETAILS Indicate if the two yearold receivesor needs support for any of the following (tick all that apply):
Speech and Language needs Developmental / learning delay

Emotional/behaviour problems Physical Development

None of the above
Please add supporting information below and use additional pages if required. It is important to focus directly on the needs of the twoyearold child.
Communication and Language
Personal, Social and Emotional Development
Physical Development
If the family are claiming any of the following benefits, please tick the appropriate box(es):
Income support Income related Employee and Support Allowance

Income based job seekers allowance The guaranteed element of State Pension Credit
Support under V1 of the Immigration and Asylum Act 1999
Extra working tax credit, provided you are not entitled to Working Tax Credit and have an annual income (as assessed by HM Revenue & Customs) that does not exceed £16190
Working Tax Credit ‘run-on’ the payment someone may receive for a further four weeks after they stop qualifying for Work Tax Credit
Office use only:Outcome Accepted  Declined  More info. required  Panel date……… …….. Terms......
Does the 2 year old: Have a named Social Worker? Yes No (please name)…

Have any other support worker (E.g, Family Support, Homestart) Yes No (please name)…
State if any form of Support Plan in place,(e.g CAF, Family Support, Child in Need, Child Protection) ……………….

Attend a regular nursery placement? Yes No How is this funded…
Please indicate if the family meet any of the following characteristics (tick all that apply):
Lone parent household Teenage parents
Parents with health issues Workless household

Parents with disability Gypsy, Roma and/or traveller families
Families who have / are experiencing Families who have / are
domestic abuse experiencing substance abuse

Asylum seeking / refugee families Child In Care

Part of a black or minority ethnic group None of the above
Nominator’s details: please complete below
Name / Telephone
Address
Email address
Agency & post
Family Consent
Prior to nomination, family consent must be obtained. Each nomination will be considered by a selection panel and will be compared against the programme criteria.
A nomination does not guarantee a placement for the two year old.
Nominator I confirm that I have discussed the nomination with the family.
Signed (nominator): …………………………………………. Name: …………………………………. ….. Date: ……………..
Family(Nominator to clarify the consent statements below and strike out any that family do not agree to).
I/We agree with this referral and confirm that the information above is correct. I/We understand that the information recorded on this form, and any relevant information gained, will be shared with other services such as Health Visitors and Children’s Centres, stored and used for the purposes of providing services to me and/or my family.
I/We understand that this nomination is for funding from the two-year-old education grant but may also result in further services being suggested as a result of information sharing and for the purpose of developing services.
I/We understand the reasons for information sharing and that consent to share information can be limited or withdrawn at any time.
I/We will inform the nominator if any of the above information changes.
I/We agree / do not agree that this information will be shared with my local Children’s Centre who will register me to use their services and that I can withdraw them at any time.
Signed: ………………………………………..…….. Name: ……………………….……………….…….... Date: ………..……
(Parent/Carer)
Signed: ………………………………..…………..… Name: ………………..……………..….…………..... Date: …………..…
(Parent/Carer)
The information we hold is kept securely in computer or in paper files in line with The Data Protection Act 1998.
Please return this completed form and any supporting information to:
Susan Atkins, FEYE and Finance Manager, Warrington Borough Council, 2nd Floor New Town House, Buttermarket Street, Warrington, WA1 2NL. Tel: 01925 442983, Fax: 01925 443153.