office use: intake: september 20/jan 21/april 21

Registration Form 2020-2021

Selly Oak Nursery School is committed to safeguarding and promoting the welfare

of children and young people and expects all people to share its commitment

Data Protection Act 1998 – This information is being collected to administer your

child’s progress though the education system. It may be shared with the Birmingham

City Council Children’s Services, the Department for Education, Connexions, relevant health and welfare

practitioners, Church or faith Authorities and other schools or educational establishments with whom your

child becomes associated.

PLACE REQUIRED (please tick)

PLEASE INDICATE YOUR PREFERRED CHOICES EG. 1ST, 2ND, 3RD – TICKING THE

BOXES MAY RESULT IN YOUR PREFFERED CHOICE NOT BEING OFFERED.

2.5 days Mon, Tues, Wed am 2.5 days Wed pm, Thurs, Fri

3 days Mon, Tues, Wed 3 days Wed, Thurs, Fri

Full Time (Mon – Fri)

CHILD’S DETAILS

Legal Surname _________________________ Legal Forename(s)______________.

Other Legal Names: ______________________ Gender: MALE FEMALE

Name child is known as, if different from above: _________________________________

Date of Birth: __________________________________________________________

Country of Birth___________________ Nationality_______________________________

Ethnicity_________________________Religion__________________________________

HomeAddress:_____________________________________________________________

_____________________________________Postcode____________________________

Office Use: INTAKE: SEPTEMBER 20/JAN 21/APRIL 21

Full birth certificate seen signed………............ NHS No........................................................ Signed ...............................

Proof of address seen (mortgage statement/rental agreement/council tax bill*) □ signed……………………………………………….

Proof of address seen (mortgage statement/rental agreement/council tax bill*) signed ………………………………………….

FULL TIME ENTITLED YES NO signed

Please circle the language / languages your child speaks indicating their main language with a cross (X)

Code Description Code Description Code Description

ACL Acholi CHIC Chinese (Cantonese) HEB Hebrew

ADA Adangme CHIH

Chinese (Hokkien/Fujianese) HER Herero

AFA Afar-Saho CHIK Chinese (Hakka) HGR Hungarian

AFK Afrikaans CHIM

Chinese (Mandarin/Putonghua) HIN Hindi

AKA Akan/Twi-Fante CKW Chokwe IBA Iban

AKAF Akan (Fante) CRN Cornish IDM Idoma

AKAT Akan (Twi/Asante) CTR Chitrali/Khowar IGA Igala

ALB Albanian/Shqip CWA Chichewa/Nyanja IGB Igbo

ALU Alur CYM Welsh/Cymraeg IJO Ijo (any)

AMR Amharic CZE Czech ILO Ilokano

ARA Arabic DAN Danish ISK Itsekiri

ARAA Arabic (any other) DGA Dagaare ISL Icelandic

ARAG Arabic (Algeria) DGB Dagbane ITA Italian

ARAI Arabic (Iraq) DIN Dinka/Jieng ITAA Italian (any other)

ARAM Arabic (Morocco) DUT Dutch/Flemish ITAN Italian (Napoletan)

ARAS Arabic (Sudan) DZO Dzongkha/Bhutanese ITAS Italian (Sicilian)

ARAY Arabic (Yemen) EBI Ebira JAV Javanese

ARM Armenian EDO Edo/Bini JIN Jinghpaw/Kachin

ASM Assamese EFI Efik-Ibibio JPN Japanese

ASR Assyrian/Aramaic ENB Believed to be English* KAM Kikamba

AYB Anyi-Baule ENG English* KAN Kannada

AYM Aymara ESA Esan/Ishan KAR Karen (any)

AZE Azeri EST Estonian KAS Kashmiri

BAI Bamileke (any) EWE Ewe KAU Kanuri

BAL Balochi EWO Ewondo KAZ Kazakh

BEJ Beja/Bedawi FAN Fang KCH Katchi

BEL Belarusian FIJ Fijian KGZ Kirghiz/Kyrgyz

BEM Bemba FIN Finnish KHA Khasi

BHO Bhojpuri FON Fon KHY Kihaya/Luziba

BIK Bikol FRN French KIN Kinyarwanda

BLT Balti Tibetan FUL Fula/Fulfulde-Pulaar KIR Kirundi

BMA Burmese/Myanma GAA Ga KIS Kisi (West Africa)

BNG Bengali GAE Gaelic/Irish KLN Kalenjin

BNGA Bengali (any other) GAL Gaelic (Scotland) KMB Kimbundu

BNGC

Bengali (Chittagong/Noakhali) GEO Georgian KME Kimeru

BNGS Bengali (Sylheti) GER German KNK Konkani

BSL British Sign Language GGO Gogo/Chigogo KNY Kinyakyusa-Ngonde

BSQ Basque/Euskara GKY Kikuyu/Gikuyu KON Kikongo

BUL Bulgarian GLG Galician/Galego KOR Korean

CAM Cambodian/Khmer GRE Greek KPE Kpelle

CAT Catalan GREA Greek (any other) KRI Krio

CCE Caribbean Creole English GREC Greek (Cyprus) KRU Kru (any)

CCF Caribbean Creole French GRN Guarani KSI Kisii/Ekegusii (Kenya)

CGA Chaga GUJ Gujarati KSU Kisukuma

CGR Chattisgarhi/Khatahi GUN Gurenne/Frafra KUR Kurdish

CHE Chechen GUR Gurma KURA Kurdish (any other)

CHI Chinese HAU Hausa KURM Kurdish (Kurmanji)

CHIA Chinese (any other) HDK Hindko KURS Kurdish (Sorani)

Code

Description

Code

Description

Code

Description

LAO Lao NOT Information not obtained* SHO Shona

LBA Luba NUE Nuer/Naadh SID Sidamo

LBAC Luba (Chiluba/Tshiluba) NUP Nupe SIO Sign language (other)

LBAK Luba (Kiluba) NWA Newari SLO Slovak

LGA Luganda NZM Nzema SLV Slovenian

LGB Lugbara OAM Ambo/Oshiwambo SND Sindhi

LGS Lugisu/Lumasaba OAMK Ambo (Kwanyama) SNG Sango

LIN Lingala OAMN Ambo (Ndonga) SNH Sinhala

LIT Lithuanian OGN Ogoni (any) SOM Somali

LNG Lango (Uganda) ORI Oriya SPA Spanish

LOZ Lozi/Silozi ORM Oromo SRD Sardinian

LSO Lusoga OTB

Believed to be other than English* SRK Siraiki

LTV Latvian OTH Other than English* SSO Sotho/Sesotho

LTZ Luxemburgish OTL Other language SSOO

Sotho/Sesotho (Southern)

LUE Luvale/Luena PAG Pangasinan SSOT

Sotho/Sesotho (Northern)

LUN Lunda PAM Pampangan SSW Swazi/Siswati

LUO Luo (Kenya/Tanzania) PAT Pashto/Pakhto STS Tswana/Setswana

LUY Luhya (any) PHA Pahari/Himachali (India) SUN Sundanese

MAG Magahi PHR Pahari (Pakistan) SWA Swahili/Kiswahili

MAI Maithili PNJ Panjabi SWAA Swahili (any other)

MAK Makua PNJA Panjabi (any other) SWAC Comorian Swahili

MAN Manding/Malinke PNJG Panjabi (Gurmukhi) SWAK Swahili (Kingwana)

MANA Manding/Malinke (any other) PNJM Panjabi (Mirpuri) SWAM

Swahili (Brava/Mwiini)

MANB Bambara PNJP Panjabi (Pothwari) SWAT Swahili (Bajuni/Tikuu)

MANJ Dyula/Jula POL Polish SWE Swedish

MAO Maori POR Portuguese TAM Tamil

MAR Marathi PORA Portuguese (any other) TEL Telugu

MAS Maasai PORB Portuguese (Brazil) TEM Temne

MDV Maldivian/Dhivehi PRS Persian/Farsi TES Teso/Ateso

MEN Mende PRSA Farsi/Persian (any other) TGE Tigre

MKD Macedonian PRSD Dari Persian TGL Tagalog/Filipino

MLG Malagasy PRST Tajiki Persian TGLF Filipino

MLM Malayalam QUE Quechua TGLG Tagalog

MLT Maltese RAJ Rajasthani/Marwari TGR Tigrinya

MLY Malay/Indonesian REF Refused* THA Thai

MLYA Malay (any other) RME Romany/English Romanes TIB Tibetan

MLYI Indonesian/Bahasa Indonesia RMI Romani (International) TIV Tiv

MNA Magindanao-Maranao RMN Romanian TMZ Berber/Tamazight

MNG Mongolian (Khalkha) RMNM Romanian (Moldova) TMZA

Berber/Tamazight (any other)

MNX Manx Gaelic RMNR Romanian (Romania) TMZK

Berber/Tamazight (Kabyle)

MOR Moore/Mossi RMS Romansch TMZT Berber (Tamashek)

MSC Mauritian/Seychelles Creole RNY Runyakitara TNG

Tonga/Chitonga (Zambia)

MUN Munda (any) RNYN Runyankore-Ruchiga TON Tongan (Oceania)

MYA Maya (any) RNYO Runyoro-Rutooro TPI Tok Pisin

NAH Nahuatl/Mexicano RUS Russian TRI Traveller Irish/Shelta

NAM Nama/Damara SAM Samoan TSO Tsonga

NBN Nubian (any) SCB Serbian/Croatian/Bosnian TUK Turkmen

NDB Ndebele SCBB Bosnian TUL Tulu

NDBS Ndebele (South Africa) SCBC Croatian TUM Tumbuka

NDBZ Ndebele (Zimbabwe) SCBS Serbian TUR Turkish

NEP Nepali SCO Scots UKR Ukrainian

NOR Norwegian SHL Shilluk/Cholo UMB Umbundu

Code Description Code Description

URD Urdu WOL Wolof

URH Urhobo-Isoko WPE

West-African Pidgin English

UYG Uyghur XHO Xhosa

UZB Uzbek YAO Yao/Chiyao (East Africa)

VEN Venda YDI Yiddish

VIE Vietnamese YOR Yoruba

VSY Visayan/Bisaya ZND Zande

VSYA Visayan/Bisaya (any other) ZUL Zulu

VSYH Hiligaynon ZZZ Classification pending

VSYS Cebuano/Sugbuanon

VSYW Waray/Binisaya

WAP

Wa-Paraok (South-East Asia)

WCP

West-African Creole Portuguese

*Categories marked with an asterisk - Believed to be English, English, Information not obtained, Believed to be other than English, Other than English and Refused - may be used by schools that have no need to use individual language codes. Stage in speaking English: Early Developing Established

Are you newly arrived in Britain: YES NO If yes, date arrived ........................

Status in country: Permanent Temporary Refugee Asylum Seeker Traveller

Mode of travel: Bus Car Car Share Cycle Train Taxi Walk Property type: House Flat floor.. Maisonette

Do you have access to a garden: YES NO

OUT OF SCHOOL CLUB

Do you need extended provision? Please tick

Breakfast Club After School Club

Please tick

requirements

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

AM 7.30 – 8.45 am

PM 3.00 – 5.45 pm

How did you hear about the nursery? Newsletter / website / word of mouth / other (please

specify)

Parents’ Details Home Address 1

Post Code

Home Telephone No.1

Mobile No.1

Work number 1

Email address 1

When resident at main home

address?

Please Tick:

__Monday

__Tuesday

__Wednesday

__Thursday

__Friday

Name of parent / carer 1:

Relationship to child:

Date of Birth:

Password:

Password hint:

Has Parental Responsibility

Y / N

Home Address 2

Post Code

Home Telephone No.2

Mobile No.2

Work number 2

Email address 2

When usually staying at this

address?

Please Tick:

__Monday

__Tuesday

__Wednesday

__Thursday

__Friday

Name of parent / carer 2:

Relationship to child:

Date of Birth:

Password:

Password hint:

Has Parental Responsibility

Y / N

Parent 1 occupation: _____________________ Place of work: ____________________

Parent 2 occupation: _____________________ Place of work: ____________________

List all people who have parental responsibility for this child:

Is there any reason e.g. Court order, which might prevent another individual: having contact with

your child or the school, or from receiving information from the School? Y / N

Name of Person:

Reasons why information should not be shared or access given:

List of evidence seen (e.g. Court order):

General Details

Position in family: ___________________

siblings age and school________________________________________________________

Previous day care / nursery / child minder / stay and play:

Medical and Dietary Information

GP Name and address________________________________________________________

________________________________________________________________________

Tel No___________________________________

Health Visitor name and address _____________________________________________

Tel No___________________________________

Social Worker name and address-if applicable____________________________________

_____________________________________________Tel No____________________

Referrals to Specialist Support Service / Health & Social Care / Hearing / Paediatrician /

Vision / Educational Psychologist / Speech & Language (please circle)

Referral contact details_________________________________________________

Medical conditions ____________________________________________________

Known allergies ______________________________________________________

Regular medication____________________________________________________

Special Dietary Requirements____________________________________________

Medical Emergency Consent

In the event of an injury I understand that all reasonable attempts will be made to

contact me. However I agree that medical and dental treatment will be given to my child

if necessary, including the administration of general anaesthetic and/or surgical

operations, in accordance with the recommendation of a medical practitioner

Signed …………………………………Relationship to child ……………………… Date …….

I agree to simple First Aid being administered to my child but ask you to note that

he/she is allergic to the following:

Signed _________________________________________________

APPLICATION FOR FREE SCHOOL MEALS

APPLICATION FOR FREE SCHOOL MEALS: April 2011

You may print this form and complete it manually. Or, you may save it to the hard drive on your PC and complete this form online. Place the cursor in the shaded area and start typing. Use the TAB key

to move from one field to the next. Insert your responses, print the form and sign it where required.

You will qualify for free school meals if you or your partner are receiving: - Income Support (IS); - Income Based Jobseekers Allowance (IBJSA); - Support under part VI of the Immigration and Asylum Act 1999; or - Child Tax Credit, provided they are not entitled to Working Tax Credit*(see page 2) and have an

annual income, as assessed by the Her Majesty’s Revenue & Customs that does not exceed £16,190;

- An income-related employment and support allowance (irESA) (this benefit was introduced on 27 October 2008)

- Guarantee element of State Pension Credit. To apply please complete and return this form to the school secretary and at the same time provide evidence of entitlement to any of the above.

School

Your address

Postcode Home Tel No

You and Your Partner You Your Partner

Title Mr Mrs Ms Miss Mr Mrs Ms Miss

Surname / Family Name

Other Names

Date of Birth / /

/ /

National Insurance Number

Do you or your partner receive Income Support or Income Based Job Seekers Allowance or irESA?

Yes

No - you cannot get free meals

AND / OR: Child Tax Credit (CTC) only - gross income of no more than £16,190

Yes


AND / OR: Support under Part VI of the Immigration and Asylum Act 1999

Yes


AND / OR: Guarantee element of State Pension Credit

Yes


This documentation is treated in accordance with The Data Protection Act 1998

O /POLICIES/FINANCE POLICIES

APPLICATION FOR FREE SCHOOL MEALS (continued)

Children living with you who go to school

Full Name Sex Date of Birth School

Backdating Does this apply to you? If you are not sure get help to fill in this part

School meals are provided free from the date of your claim. However, if you have a good enough reason for not claiming earlier and you have paid for your child’s meals we can refund you for up to 3 months. If you think that your free meals should be backdated tell us the date from which you wish to claim and the reason why below.

I wish to claim free meals from / /

I did not apply earlier because

Declaration: If you give false information you could be prosecuted

- As far as I know the information I have given is complete. - I agree that you may make any enquiries to check the information I have given. - I will tell you at once if my circumstances, income or savings change. - I will tell you at once if there is any change in the circumstances or income of the people living in my

house.

Your signature Date

This documentation is treated in accordance with The Data Protection Act 1998


The Early Years Pupil Premium

From April 2015, nurseries, schools, childminders and other childcare providers will be able

to claim extra funding through the Early Years Pupil Premium to support children’s

development, learning and care. We wanted to write to you to explain what the Early Years

Pupil Premium is, explain who is eligible for this funding and, importantly, to ask you to fill out

the enclosed forms so that we as a provider can claim the extra funding.

National data and research tells that children eligible for free school meals tend to do less

well, for example in 2014 45% of children eligible for free school meals achieved the

expected level at the end of the early years foundation stage compared with 64% of other

children. The Early Years Pupil Premium will provide us with extra funding to close this gap.

The Early Years Pupil Premium provides an extra 53 pence per hour for three and four year

old children whose parents are in receipt of certain benefits or who have been in care or

adopted from care. This means an extra £302 a year for each child taking up the full 570

hours funded entitlement to early education. This additional money could make a significant

difference to us.

We can use the extra funding in any way we choose to improve the quality of the early years

education that we provide for your child. This could include for example additional training

for our staff on early language, investing in partnership working with our colleagues in the

area to further our expertise or supporting our staff in working on specialised areas such as

speech and language.

It is well documented that high quality early education can influence how well a child does at

both primary and secondary school so we do want to make the most of this additional

funding. You may be aware if you have older children that a pupil premium has been available

for school age children and it has proved to have given a real boost to the children receiving

the funding. We want to do the same for our early years children entitled to this funding.


SELLY OAK NURSERY SCHOOL REGISTRATION FORM

EARLY YEARS PUPIL PREMIUM VOLUNTARY REGISTRATION

We need information about you and your child, to provide the best education and support by making sure

we receive all the government funding to which we and your child are entitled. Please complete this form

and return at the home visit.

ABOUT YOUR CHILD/CHILDREN

Child’s Last Name Child’s First Name Child’s Date of Birth

Name of preschool, nursery, childminder

D D M M Y Y Y Y Selly Oak Nursery School

D D M M Y Y Y Y Selly Oak Nursery School

PARENT/GUARDIAN DETAILS

Parent/Guardian 1 Parent/Guardian 2

Last name

First Name

Date of Birth D

M Y D M Y

National Insurance Number

National Asylum Support Service (NASS) Number*

/

/

/

/

Daytime Telephone Number

Mobile Number

Address Postcode:

Postcode:

FAMILY INCOME AND BENEFIT DETAILS

Is your joint family income over £16,190 per year? (Please place an X in the appropriate box).

Yes No

If you have ticked yes, you do not need to complete the next section and can go straight to the declaration at the end of the form.


CHARGING AND REMISSIONS POLICY STATEMENT

RATIONALE

Selly Oak Nursery is committed to providing quality education based on equality of opportunity.

The Governing Body recognises the valuable contribution that the wide range of additional activities

can make towards a child’s education.

We aim to promote and provide activities as part of broad and balanced learning experiences for all

children.

When considering activities to support and enhance the curriculum, the following considerations are

always made

• The value of the activity in relation to age/needs of children

• The cost of the activity set against their educational value

• How the activity will be paid for

• The appropriate process of raising funds

• An assessment of whether the educational aims can be met in another way

• Reference to additional or hidden costs eg lunch money/pocket money

CONTEXT

The law states that education provided during the school day must be free. This definition includes

materials, equipment and transport provided in school hours by the Local Authority or the School. No

child may be left out of an activity because the parents cannot or will not make a contribution of any

kind.

AIMS

• To make the school activities accessible to all children regardless of income

• To provide a process which allows activities to take place at a minimum cost to parents,

children and the school and which acknowledges the cost of such activities to the school’s

budget

REMISSIONS

The aim of this policy is to ensure all children gain fully from everything the school offers and is

based on an understanding of the relationship between low income, entitlement and access. This

policy takes into account the very real and persistent difficulties which those on low income have in

meeting the cost of educational activities for their children.

For families in receipt of Income Support, Council tax or housing benefit or family credit are

unwilling or unable to pay all or in part of any cost of any educational visit/activity, no charge will be

made.

For children in receipt of Free School Meals, arrangement will be made for them to receive a packed

lunch from the school when on a visit. Parents and Carers will be notified of proposed trips and

probable cost well in advance and opportunities to pay in instalments will be offered.

There will be no obligation for any parent to make a voluntary contribution towards the cost of school

activities or to the school fund. Children will be treated equally whether or not parents have

contributed.

The Governing Body may wish to remit in full or in part the cost of other activities for any particular

groups of parents, for example, in the case of family hardship. When arranging a chargeable activity

such parents will be invited in confidence for the remission of charges in full or in part. The Head

Teacher in consultation with the Chair of Governors will make authorisation for such remission.


GENERAL

The Governing Body may, from time to time, amend the category of activity for which a charge may

be made. Nothing in this policy statement precludes the Governing Body from inviting parents to

make a voluntary contribution towards the cost of additional activities, which take place in school

time. Parents may be advised that the continuance of an activity may depend upon voluntary

contributions, but once it has been decided to run an activity no qualifying child will be excluded on

the grounds of voluntary contributions.

We will endeavour to produce a programme of activities based on a clear set of priorities identified

by the School. Such a process will not inhibit flexibility and the capacity of the school to take

advantage of opportunities which arise during the school year.


SELLY OAK NURSERY SCHOOL PARENTAL DATA CONSENT FORM

GDPR Regulations

As a school, we are legally required to inform you as to the purpose of any data we hold in relation to

you or your child. We must also inform you where we will hold the data, who will have access to, how

long we keep it for and when we will delete / destroy it. This relates to any data we hold – whether on

paper on our computer systems.

Please be assured that we take every step to ensure the safety of this data.

Below, we have outlined the range of information we expect to hold OR are legally obliged to do so. In

each section, we have outlined what we are keeping, where it is kept and what we do with it. We

require you as a parent to acknowledge (by signing underneath) each section. By doing so, you are

acknowledging that you are happy with the arrangements.

Parents and Carers can learn more about how we hold children’s data and their rights by reading the

Privacy Notices on our website. Please note: we will endeavour to inform you in a timely manner of

any changes.

Registration Information

What? Probable

Content Why? Who? Where? When?

1 Registration

form data

Admission

form data

Capita (SIMS)

Electronic data

base

Name

D.O.B.

Address

Telephone

E Mail address

Medical Issues

Parental

Details

Emergency

contact list

Primary School

transition

forms

Legally

Required To

For Admission

To School

Well-Being of

Your Child

Communication

All Staff

(Where

Necessary)

Initially

completed on

paper then

entered onto

School’s

Information

Management

System.

Paper copy is

kept in a locked

drawer in the

main office

Held On File Throughout

Child’s Year At School.

Archived in O Drive and

password protected.

Paper Version is passed onto

new School when moving.

Each child’s records are

signed and dated by SONS

and the receiving school. As

much as possible we deliver

the records by hand. Failing

this recorded delivery is

used.

☐ I understand the purpose of this data and confirm that I am satisfied with the school’s

arrangement for managing it

Signed: _____________________________

http://www.sellyoak-nur.bham.sch.uk/about-the-school/policies/


Parent Declaration Form – Early Education Entitlement 2-4 years Data Protection Statement

The information you have provided in this form about you and your child will be used by Birmingham City

Council and your early year’s provider to process your application for early year’s education funding, and in

accordance with the General Data Protection Regulation’s and any successor legislation to the GDPR and

or the Data Protection Act 2018.

The Council will use the information provided by you on this Parental Declaration form to enable it carry

out specific functions, which it is responsible for. These include:

• To safeguard and promote the welfare of children, including children missing from education.

• Meeting funding requirements for early year’s education places in Birmingham;

• Ensuring that the early year’s providers receive appropriate early education funding for 2, 3 or 4

year old children, including supplementary payments for children with special educational needs.

• Ensuring that the early year’s providers are administrating the funding or free entitlement

appropriately including accessing information from other government departments to confirm

child eligibility.

The Council is under a duty to protect the public funds it administers, and may also use the information

you have provided on this form within the Council for the prevention and detection of fraud, in order to

check its accuracy, prevent or detect crime, protect public funds, or where otherwise required or

permitted by law. Your information may also be shared with third parties and other Local Authorities,

early year providers and the Department for Education (DfE) for audit funding requirements, or where

there is a legal requirement to do so. Your personal data will never be disclosed for marketing purposes

and will only be used for Statutory purposes which the Local Authority is empowered to act on because

it is a public body.

If you would like more information about how the DfE use your information, then please go to the

following website:

www.gov.uk/guidance/data-protection-how-we-collect-and-share-research-data

Your personal data will be collected, used, processed, stored and retained in accordance with your

legal rights and the Council’s policy as set out in our privacy notice. Our privacy notice also

contains contact details of our Data Protection Officer and the Information Governance Team. You

can view the full privacy notice on our website at

www.birmingham.gov.uk/info/20154/foi_and_data_protection/384/privacy_statement or you can

request a hard copy by writing to the Information Governance Team, 10 Woodcock Street,

Birmingham B7 4BL.

http://www.gov.uk/guidance/data-protection-how-we-collect-and-share-research-data

https://www.birmingham.gov.uk/info/20154/foi_and_data_protection/384/privacy_statement/1

http://www.birmingham.gov.uk/info/20154/foi_and_data_protection/384/privacy_statement


Parent/Carer/Guardian with Legal Responsibility Declaration

Declaration: I (name) ........................................................................................................ Of (address) ............................................... ............................................... ................................................................................................................... confirm that the information I have provided above is accurate and true. I understand and agree to the conditions set out in this document and I authorise (Name of Provider/s) ……………………………………………………………………………………………… to claim early education entitlement funding on behalf of my child. Parent/Carer/Guardian with legal responsibility

Childcare Provider

Signed

Signed

Print name

Print name

Date

Date

In collecting your data for the purposes of checking your eligibility for the 2 year-old, or 3 & 4 year old universal and extended free entitlements, Early Years Pupil Premium (EYPP), Free School Meals(FSM) or Disability Access Fund (DAF) (see notes 1 – 6), Birmingham City Council is exercising the function of a government department. Birmingham City Council is authorised to collect this data pursuant to Section 13 of the Childcare Act 2006.

Data Privacy The General Data Protection regulations (GDPR) and the Data Protection Act 2018 (the Act) puts in place certain safeguards regarding the use of personal data by organisations, including the Department for Education, local authorities, schools and other early education providers. The Act gives rights to those about whom data is held (known as data subjects), such as pupils, their parents and teachers. This includes:

• The right to know the types of data being held • Why it is being held; and • To whom it may be disclosed

Should you have any concerns relating to how your information or the information relating to your child is being or will be used, please contact your provider or Birmingham City Council. Please note that information about whether a child is in receipt of Disability Living Allowance is, under the Act, Special Category Data which should be handled appropriately. Providers are asked to pay particular note to advice from the Information Commissioner’s Office on holding personal data including sensitive personal data which is available at: https://ico.org.uk/for-organisations/guide-to-data-protection/principle-3-adequacy/

https://ico.org.uk/for-organisations/guide-to-data-protection/principle-3-adequacy/


Provider Name

Parent Declaration Form – Early Education Entitlement 2-4 years Please fully complete this form in English. All three and four year olds are eligible for a funded early education place of 15 hours a week for 38 weeks per year (term time only) or the equivalent of 570 hours stretched over the whole year. Some two year olds are also eligible for 570 hours per year subject to certain criteria – see ‘Parents Notes’. Some three and four year olds will be eligible for 30 hours per week (1140 hours per year) funded early education place (term-time or equivalent stretched). This form collects information to assess which funding you are eligible for including Free School Meals, Pupil Premium and Disability Access Fund

Child details:

Legal Forename: Legal family name:

Previous names;

Date of Birth: / / (as per birth certificate) Gender M F

Proof of date of birth seen by Proof of address seen by

Ethnicity:

Address:

Postcode:

Home Language:

Disability living Allowance Education Health Care Plan Looked After Child Adopted

Residence Order Special Guardianship Order

** If you have ticked any of the above boxes your Provider may ask you to produce evidence

Document Check Your chosen provider will need to see proof of your child’s date of birth. Documentary proof of Date of Birth Type (e.g. Birth Certificate, Passport):

Documentary proof of Address Type (e.g. Utility bill, benefit letter):

Document recorded by (name of staff member):

Date document recorded (dd/mm/yyyy):


Parent or Carer details: Title: Legal Forename: Legal Family Name:

Previously known Surname:

Address:

Postcode:

Date of birth / / (i.e. 31/08/1970) Telephone:

Email address:

National Insurance (NI) number or National Asylum Support (NASS) number:

30 hour eligibility code: Please note 30 hours cannot be funded until the term after eligibility is confirmed. Funding can only continue each term if eligibility is reconfirmed by parents every 3 months. Parents will be charged for 15 hours if eligibility is reconfirmed late. Children who have been admitted to primary school and are attending a state-funded or independent school reception class are not entitled to any additional free hours outside their school reception class.

2 year old eligibility code: 3 and 4 early years pupil premium eligibility/FSM code:

If the child lives full time with a second parent or carer, you must record the details of the second parent or carer below: Title: Legal Forename: Legal Family Name:

Previously known Surname:

Address:

Postcode:

Date of birth / / (i.e. 31/08/1970) Telephone:

Email address:

National Insurance (NI) number or National Asylum Support (NASS) number:

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You need to agree and complete this declaration form with each setting your child attends, in order to ensure that funding is paid fairly to each provider. Your child can attend a maximum of two sites in a single day and if your child attends more than one setting we will distribute the funding appropriately between the

settings.

Term Please circle– Autumn Spring Summer

Please enter total free entitlement hours attended per day*

Total number of hours per week

Number of weeks per year (e.g. 38, 51) Provider school name MON TUES WED THUR FRI

A

B C Total Daily Free Hours Attended

Start Date/s





A


Start Date/s





A


Start Date/s


Universal Provider

If your child is splitting their free entitlement across two or more settings please nominate the universal provider

(the universal provider is the provider that the15 hours universal funding will be paid to if the 15 hours extended

entitlement is lost:)

Universal provider name: Selly Oak Nursery School

Disability Access Fund (DAF)

If your child is splitting their free entitlement across two or more settings please nominate the setting where the

local authority should pay the DAF. Please note the Disability Access Fund payments can only be paid to one

provider per financial year DAF provider name; …

I confirm I am eligible for the provision below (See ‘Important Note for Parents/Carers’ overleaf)

☐ 15 hours for two year olds (see note 1)

☐ 30 hours for three and four year old (see note 2)

☐ 15 hours for three and four year old (see note 3)

☐ Disability Access Fund i.e. in receipt of DLA (see note 4)

☐ Early Years Pupil Premium (see note 5) ☐ Free School Meals (see note 6)

Please only sign the current term and it will be signed on a termly basis by the parents and

then Nursery.

Parent Signature

Date Term Autumn

Provider Signed:

Date Print Name

Parent Signature

Date Term Spring

Provider Signed:

Date Print Name

Parent Signature

Date Term Summer

Provider Signed:

Date Print Name


Important Notes for Parents/Carers Changing Provision: When a child moves early years provider after headcount day, funding will not be transferred to another provider unless an exceptional agreement has been made between the provider and the Local Authority. If a parent moves to a new provider midterm, the parent will be liable for any fees due to the new provider. Periods of extended leave – 4 weeks or more: The maximum paid absence for a child from a provision when claiming EEE funding is four consecutive weeks. If you choose to remove your child for 4 weeks or more, funding will not be paid for that term and you may be charged by your provider for any sessions you have attended. Note 1: To be eligible for 15 hours for a two year old, you must be in receipt of one of the following benefits: Income Support/Income based JSA, Income related ESA, Child Tax Credit, Working Tax credit with an assessed income of less than £16,190, Universal Credit and have an annual net income of no more than £15,400. The Guarantee element of State Pension Credit, Support under Part VI of the immigration and Asylum Act 1999, child in receipt of DLA, Child looked after by the Local Authority, or a child who has left care through adoption, Special Guardianship or Residence Order. Note 2: To be eligible for 30 hours extended entitlement pace for a three or four year old you must

earn less than £100,000 and meet one of the following criteria: Single parents working at least 16

hours per week on the minimum wage, Couples – both working at least 16 hours per week on

minimum wage, one parent is employed and the other parent is in receipt of carers benefits,

specific disability or incapacity benefits. Working parents includes those on statutory sick pay,

parental, adoption maternity or paternity leave. Please note that parents cannot receive extended

entitlement funding at a new provider if they start attendance during their Grace period. Should

you no longer be eligible for 30 hours (extended entitlement) then you will still be eligible for the 15

hours early education universal entitlement. Where your child attends 2 settings or more, you

should choose which setting will be funded for the universal 15 hours.

If parents do not reconfirm their eligibility every 3 months before the following deadlines, they will be liable for the next terms extended hours fees.

• Autumn Term – reconfirmation and application deadline date – 31st August

• Spring Term – reconfirmation and application deadline date – 31st December

• Summer Term – reconfirmation and application deadline date – 31st March Children who have been admitted to primary school and are attending a state-funded or independent school reception class are not entitled to any additional free hours outside their school reception class. Note 3: All three and four year olds are entitled to the 15 hours universal entitlement. Note 4: Three and four year old children in receipt of child DLA and who are receiving the early education entitlement are eligible for the Disability Access Fund (DAF). DAF is paid to the child’s setting as a fixed annual rate of £615. Please note this payment is not made for 4 year olds in reception classes. This is an annual payment and is only payable to one provider each


financial year. If the child is attending more than one provider. Parents should complete this form with each provider they attend including schools. Note 5: Early Years Pupil Premium (EYPP) is an additional sum of money paid to childcare providers for children of families in receipt of certain benefits including: Income Support/Income based JSA, Income related ESA, Support under Part VI of the immigration and Asylum Act 1999, the guaranteed element of State Pension Credit, Child Tax Credit (provided they’re not also entitled to Working Tax Credit and have an annual gross income of no more than £16,190), Working Tax Credit run-on, which is paid for 4 weeks after they stop qualifying for Working Tax Credit, Universal Credit and have an annual net income of no more than £7,400, Child looked after by the Local Authority, or a child who has left care through adoption, Special Guardianship or Residence Order. This funding will be used to enhance the quality of the child’s early years’ experience by improving teaching and learning. Please note that 4-year-olds in primary school reception classes who already receive the school-age pupil premium are not eligible for EYPP funding. Note 6: Free School Meals (FSM) is an additional sum of money paid to childcare providers to fund a FSM for children of families in receipt of certain benefits including: Income Support/Income based JSA, Income related ESA, Support under Part VI of the immigration and Asylum Act 1999, the guaranteed element of State Pension Credit, Child Tax Credit (provided they’re not also entitled to Working Tax Credit and have an annual gross income of no more than £16,190), Working Tax Credit run-on, which is paid for 4 weeks after they stop qualifying for Working Tax Credit, Universal Credit and have an annual net income of no more than £7,400, Child looked after by the Local Authority, or a child who has left care through adoption, Special Guardianship or Residence Order. Important Note the FSM funding is only available if your child attends a full education place before and after lunch (a full day place).

office use: intake: september 20/jan 21/april 21

Documents