OFFICIAL SENSITIVE

For referrers use

2-Year-OldFunding Application

Return completed form securely to:Early Years and Childcare Service, B1-F3, Suffolk County Council, Endeavour House, 8 Russell Road, Ipswich, IP1 2BX or to Telephone: 0345 60 800 33

Section 1: Personal Details

Child’s legal name: Male / Female
Date of birth:
Address:
Post Code: / Language spoken by parent:
Parents/Carers name: / Parents/Carers DOB:
NI No or NASS Ref.: / Telephone number(s):

Section 2: Childcare provider information (if known)

Name of provider: Postcode:
2a) Is the child already attending this childcare provider? Yes No
2b) Does the provider have space for this child? Yes No Don’t know
2c) I confirm I have given this child’s name to the setting: Yes No
Number of hours the child will attend per week ……..…….. (maximum of 15)

Section 3: Children’s Centre information

Is the family registered on eStart? Yes No (This is the Children’s Centre database)
If Yes, please provide eStart registration number:
If No, discuss and encourage parents to register with the Children’s Centre.
I agree to complete an eStart form and understand that the children’s centre will contact me.
Parent / carer signature……………………………Parent / carer name…………………………………..

Section 4: Economic eligibility criteria

Code: ECO. My Early Learning online checker reference (
Universal Credit
Income Support
Income-based Jobseekers Allowance
Income-related Employment and Support Allowance
Child Tax Credit and / or Working Tax Credit and earn no more than £16,190
The guaranteed element of State Pension Credit
Support under Part 6 of the Immigration and Asylum Act 1999
The Working Tax Credit 4-week run on (the payment you get when you stop qualifying for Working Tax Credit)

Section 5: Non-economic eligibility criteria

Code: LAA.
If the child is a Child in Care (CiC) or has left care through special guardianship (SGO) or through an adoption, residence (RO) or child arrangements order (CAO) he or she will be eligible the term after their 2nd birthday.
CiC, SGO, RO, CAO, adopted
Code: OTH.
Social Worker or Family Nurse’s name:
Contact Number & Email Address:
Child Protection (CP)
Child in Need (CIN) due to safeguarding
Referred to CIN team but did not meet the threshold[1]
Family Nurse Partnership Programme (during the term in which the child turns 2)
I confirm that the parent has given consent to sharing information on their child with the
Childcare Provider.
Parent signature……………………………Parent name…………………………………..
Code: HSD.
The child has a current Education, Health and Care plan
The childreceives Disability Living Allowance

Section 6: Referrer declaration

I confirm that I have completed this application form with the parent/carer named overleaf.
Name (please print) …………………………………… Job Title……….……………………………
Phone / email address ………………………………………….………... Date………………………
Note: Section 7 must be completed by a worker from the Early Years and Childcare team at Suffolk County Council

Section 7: Completed by Early Years and Childcare team at Suffolk County Council

Eligibility has been verified by:
Quality and AccessWorker (Full name)………………………………………………………….
Signature……………………………………… Date…………………………………………….
using: DfE Electronic checker Carefirst6 Other source
Reference number from
Data Protection:
When a family registers with a Children’s Centre they are giving consent for
the relevant information to be held by the Data Controller (the organisation that is collecting and
holding the information, in this case Suffolk County Council).

January 2018

[1]Child does not have CIN status