Confidential
Parental Declaration Form for 3 & 4 Year old Funding
To be completed by Parent/Carer wishing to claim Free Early Education for
3 & 4 Years olds

You need to complete this Declaration Form with each provider your child attends for their Free Early Education Entitlement of 15 or 30 hours per week in order to ensure the Provider can claim the funding from Kent County Council (KCC). The Early Years Registered Provider has responsibilities under the General Data Protection Regulation (GDPR) and must provide you with a copy of the provider’s Privacy Notice before you read and sign this declaration, so that you understand how your information will be used.

This Parental Declaration will be made available to The Education People and any person authorised by KCC for audit purposes.

Part One: Provider Details		
	Provider Name:                                                   	URN:   
                                                          		
	Ofsted Number:                                                   	No. of funded weeks per year:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 		

Part Two: Child Details

Legal Forename:                                                 	Flat Name/No:                                                            	
Middle Name(s):                                                   	House Name/No:                                                         	
Legal Surname:                                                    	Street:                                                                          	
Date of Birth:                                                        	Town/City:                                                                   	
Known as:                                                            	Postcode:                                                                    	
Additional Information – for Early Years Census	
Gender:                                                                	Ethnicity:                                                                       	
Language:                                                              	                                                                                            	
Details of Date of Birth Evidence	
Document seen as proof of Date of Birth:                  (either passport or birth certificate)	Checked by: (Staff name)                                                                	
Document Identification Number:                          	Date document seen:                                                 	

Part Three: 3 & 4 Year Old Funding: Please indicate where your child will be attending and which entitlement will be accessed at each provision

 Year:
 	
	 Term:

Name of Provider A:	                                                	Total Universal
Hours per Week	               	Total Extended
Hours per Week	                	
Name of Provider B:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	                	
Name of Provider C:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	                	
Claim Start Date for
Funded Hours:	                   	Number of weeks claiming	                     	Hours Per Week	                     	Stretched Funding
	YES/  NO
	
Monday	              	Tuesday	               	Wednesday	                    	Thursday	                   	Friday	                     	
If you are claiming for:
•	Universal Hours (up to 15 hours only) please complete Part Seven
•	Universal and Extended, Extended only and\or Early Years Pupil Premium please complete Parts Four, Six and Seven

Version Updated 02/06/20

•	Universal Hours (up to 15 hours only) and Early Years Pupil Premium please complete Parts Five, Six and Seven

Part Four: 30 Hours Free Childcare—Extended Entitlement Check

2

30 Hours Eligibility Code (DERN):                                                                                                               

I give permission for the Early Years Provider named in this agreement to submit my details to KCC to complete an ECS Check to validate my code and confirm eligibility for 30 hours of Free Childcare.

Signed		Print Name	                                                  	Date	                           	
I understand that if my circumstances change and I am no longer eligible for the extended entitlement, my child’s universal 15 hours will be paid in line with information supplied in Part Three or in full to the nominated provider named below:

Name of Provider to claim universal hours	
if no longer eligible for 30 hours:	                                                                                          	

Part Five: Early Years Pupil Premium (EYPP)

I give permission for the Early Years Provider named in this agreement to complete an application for EYPP on my
behalf.

Signed	                                                    	Print Name	                                               	Date	                         	

Part Six: Parent Details

This must be the details of the person with parental responsibility for the child and who is receiving the benefit/credit or who created the childcare services account on the HMRC website.

Forename:	                                                  	Surname:	                                                       	
Date of Birth:	                                                 	National Insurance
Number:	                                                       	

Part Seven: Declaration of person with legal responsibility for the named child:

Declaration of person with legal responsibility for the named child:

1.	I confirm I have read and understood the provider’s Privacy Notice.

2.	I confirm I have read and accept the provider’s Free Early Education offer and Fee Structure.

3.	I understand it is my responsibility to ensure the provider(s) are aware of the hours I wish to claim and that these do not collectively exceed the weekly maximum of 15 hours (or 30 hours if applicable).

4.	I understand that if my child attends more than the maximum 15 hours per week (or 30 hours if applicable) the provider(s) involved will charge for the hours my child attends in excess of his/her Free Early Education.

5.	I confirm that the details I have supplied are accurate and true.

6.	I understand that once the annual Free Early Education of 570 hours (or 1140 hours, if applicable) has been reached, any additional hours will be charged for by the provider. The annual entitlement starts in the term in which my child first became eligible for funding.

7.	I understand that if I choose to change providers during the term and my child has already been funded for the term that I ma y have to pay the new provider for the hours my child attends for the remainder of the term.

8.	I understand that my provider will need to see my child’s birth certificate or passport and if applicable, change of name deed prior to claiming their Free Early Education for the first time.

I declare the above information to be correct at the time of completion and if, for any reason, my claim does not meet the eligibility criteria I will be responsible for paying the setting for any hours my child attends.

Parent Name	                                         	Parent Signature	                                         	Date	                      	
 Name of Staff Member Present on Completion 	                                                                                                    	

If your child is in receipt of Disability Living Allowance, please advise your Provider. Your child may be eligible for Disability Access Funding.

Version Updated 02/06/20

Provider Information—This form should be retained for audit purposes from the financial year the form was dated plus 6 years
  Continuation of Funded Hours for 3 & 4 Year Olds: Please indicate where your child will be attending and 
  which entitlement will be accessed at each provision (To be signed no more than 6 weeks prior to the end of the previous term)
Child Name:		
Year:
	 	Term:		
Name of Provider A:	                                                	Total Universal
Hours per Week	               	Total Extended
Hours per Week	               	
Name of Provider B:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	               	
Name of Provider C:	                                                	Total Universal
Hours per Week	              	Total Extended
Hours per Week	               	
Claim Start Date for
Funded Hours:	                   	Number of weeks claiming	
                     	Hours Per Week	
                     	Stretched Funding
	YES/  NO
	
Monday	              	Tuesday	             	Wednesday	                 	Thursday	                 	Friday	                   	
 Additional information / changes to information given on page 1 or 2:

                                                                                                                                                                                       
                                                                                                                                                                                         	
  Parent Name

	                                          	Parent Signature	                                          	Date	                            	
Name of Staff Member Present on Completion	                                                                                                       	

                          

             
 Provider Information—This form should be retained for audit purposes from the financial year
                                                                              the form was dated plus 6 years

     
  Continuation of Funded Hours for 3 & 4 Year Olds: Please indicate where your child will be attending and 
  which entitlement will be accessed at each provision (To be signed no more than 6 weeks prior to the end of the previous term)
Child Name:		
Year:
	 	Term:		
Name of Provider A:	                                                	Total Universal
Hours per Week	               	Total Extended
Hours per Week	               	
Name of Provider B:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	               	
Name of Provider C:	                                                	Total Universal
Hours per Week	              	Total Extended
Hours per Week	               	
Claim Start Date for
Funded Hours:	                   	Number of weeks claiming	
                     	Hours Per Week	
                     	Stretched Funding
	YES/  NO
	
Monday	              	Tuesday	             	Wednesday	                 	Thursday	                 	Friday	                   	
 Additional information / changes to information given on page 1 or 2:

                                                                                                                                                                                       
                                                                                                                                                                                         	
  Parent Name

	                                          	Parent Signature	                                          	Date	                            	
Name of Staff Member Present on Completion	                                                                                                       	

	

                          

             

Provider Information—This form should be retained for audit purposes from the financial year
                                                                              the form was dated plus 6 years

       Continuation of Funded Hours for 3 & 4 Year Olds: Please indicate where your child will be attending and 
  which entitlement will be accessed at each provision (To be signed no more than 6 weeks prior to the end of the previous term)
Child Name:		
Year:
	 	Term:		
Name of Provider A:	                                                	Total Universal
Hours per Week	               	Total Extended
Hours per Week	               	
Name of Provider B:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	               	
Name of Provider C:	                                                	Total Universal
Hours per Week	              	Total Extended
Hours per Week	               	
Claim Start Date for
Funded Hours:	                   	Number of weeks claiming	
                     	Hours Per Week	
                     	Stretched Funding
	YES/  NO
	
Monday	              	Tuesday	             	Wednesday	                 	Thursday	                 	Friday	                   	
 Additional information / changes to information given on page 1 or 2:

                                                                                                                                                                                       
                                                                                                                                                                                         	
  Parent Name

	                                          	Parent Signature	                                          	Date	                            	
Name of Staff Member Present on Completion	                                                                                                       	

  Continuation of Funded Hours for 3 & 4 Year Olds: Please indicate where your child will be attending and 
  which entitlement will be accessed at each provision (To be signed no more than 6 weeks prior to the end of the previous term)
Child Name:		
Year:
	 	Term:		
Name of Provider A:	                                                	Total Universal
Hours per Week	               	Total Extended
Hours per Week	               	
Name of Provider B:	                                                	Total Universal
Hours per Week	                	Total Extended
Hours per Week	               	
Name of Provider C:	                                                	Total Universal
Hours per Week	              	Total Extended
Hours per Week	               	
Claim Start Date for
Funded Hours:	                   	Number of weeks claiming	
                     	Hours Per Week	
                     	Stretched Funding
	YES/  NO
	
Monday	              	Tuesday	             	Wednesday	                 	Thursday	                 	Friday	                   	
 Additional information / changes to information given on page 1 or 2:

                                                                                                                                                                                       
                                                                                                                                                                                         	
  Parent Name

	                                          	Parent Signature	                                          	Date	                            	
Name of Staff Member Present on Completion