EARLY YEARS APPLICATION FOR 
ACCESS FUND
V6

Requests can only be made for children at Early Years SEN Support or who have a Statement of SEN or EHC Plan. 

Form must be typed and returned to: Educational Psychology & Early Years SEN Support Service, Third Floor, Empire House, Wakefield Old Road, Dewsbury, WF12 8DJ.   PLEASE BE SURE TO USE THE CORRECT POSTAGE – FORMS WILL NOT BE COLLECTED WHERE POSTAGE IS UNDERPAID

In order to help settings/professionals to complete this form suggestions or comments are in italics.  

Section 1 – Application Details	
This is a New Application 		
	This Application is for Continuation of Funding  	
	Has this child been referred to Early Years SEN Support?	
	
Section 2 – Child Details	
Child’s Name:	     	Date of Birth:	     	
Home Address:

	     	
Looked After Child (LAC):		Potential School start date:	     	

Section 3 – Setting Details	
Setting Name:	     	
Attendance Start Date:	     	Adult to Children Ratio in room:	     	
Setting Address:

	     	
Setting telephone no:	     	
Setting email:		
Setting Main Contact name:		Role/title:	     	
Contact email (if different to setting):	     	
Signature of person completing the form:	     	
Name of person completing the form (printed):	     	Date	     	
Invoice Address (if different to Setting)	     	
Section 4 – Background Information	
Background information about the child and his/her additional needs.  ( Brief Summary)	
     
	
Barriers to accessing play/learning.  Outline the areas which are causing concern and require support that is additional to and different from the normal provision provided by the setting:	
     
	
Supporting documentation: 	
  EYFS Tracker 
  IEP (2 most recent reviewed plus current) OR   My Support Plan
  Provision Map
  Health Care Plan
  Risk Assessment
  Any other current medical/professional’s reports (ensure consent to send these has been gained)

Please Note - Without submitting appropriate evidence this application will not be considered.
	
Section 5 – Additional Resources.  	

  Funded childminder places for support for children with additional needs within their setting  

  Additional member of staff from your setting - Hourly Rate of additional member of staff: £      
	
Clearly state how you would use Access Funding if awarded	
     
	
If this application is for an extension of funding please state how the funding has benefitted the child/young person.	

     	
Section 6 – Other Agency Involvement.  Give details of agencies/professionals currently involved with this child:	
Name of Agency/Professional	Role / Title	
     	     	
     	     	
     	     	
     	     	
     	     	
     	     	
Section 7 – Details of current placement/provision. Please specify the total amount of hours per day for each type: 	

Type	Please give TOTAL HOURS for each day (not times attended)	
	Monday	Tuesday	Wednesday	Thursday	Friday	Total for week	
School Hours Term Time Childcare	     	     	     	     	     	     	
Before/After School Childcare	     	     	     	     	     	     	
Holiday           Childcare	     	     	     	     	     	     	
	
No of children in room	     	     	     	     	     	n/a	
No of adults in room	     	     	     	     	     	n/a	
Does the child ‘Stretch’ their attendance through the year?	     	
Does the child attend any other setting?	     	If Yes – how often:	                                        	
Name of other setting/school:	     

Section 8 – Parent/Carer’s Consent.  Please note that the parent/carer’s consent is essential.  The panel will not discuss any request without the parent/carer’s consent and signature.	
Data Protection – How we use your information.

The information provided in this form will be used at an Access Fund panel to decide what level of funding should be granted to support your child in their pre-school setting.
Further information
If you would like further information about how we manage your data, please see the privacy notice for Kirklees Council at www.kirklees.gov.uk/privacy

If you would like further information about the privacy notice for Early Years Access Fund, please contact: Educational Psychology & Early Years Support Service, telephone 01924 483744 or email dewsbury.psychology@kirklees.gov.uk

If you have any worries or questions about how your personal data is handled, please contact the Data Protection Officer at DPO@kirklees.gov.uk or by ringing 01484 221000.

I have read and agree with the information given in this form and consent to the form and the attached documents being submitted for discussion at the Access Panel.

Parent/Carer Signature:						Date:

Name (printed): 
	
If parents have any additional information they would like to add please write it here:
     	
Section 9 - Conditions of Early Years Access Funding - Please ensure you have read and understand these conditions of funding before signing.
	
•	Eligibility is dependent on the setting being registered with Ofsted on the Early Years Register.

•	The setting’s full compliance with the Early Years Access fund process is required, including completion of all relevant paperwork and provision of any information requested by the panel e.g. copies of IEPs, Care Plans, My Support Plans etc.

•	For audit and monitoring purposes, the Local Authority may wish to view your records/registers relating to claims for Early Years Access Funding.

•	Early Years Access Funding is a contribution towards the cost of providing additional support and must be used specifically in support of the named child.  Misuse of this funding will lead to it being withdrawn.

•	The setting is responsible for the recruitment and employment of any additional staff members required to deliver the support.

•	Funding periods are based on school terms: April to August, September to December, January to March.  Panel dates and deadlines for applications are notified to settings by email.  It is the setting’s responsibility to ensure an up to date email address is held by Kirklees, send to childcare.sufficiency@Kirklees.gov.uk

•	Following Panel a letter confirming funding will be sent with an invoice template and guidance, an email giving a purchase order number which will be used for the duration of funding will then be sent by Kirklees Marketplace.   Each invoice must be submitted using the Kirklees template invoice and include: the correct purchase order number, a unique invoice reference number provided by the setting, details of the number of hours being claimed and the dates covered.

•	Access Fund operates on a Financial Year basis (1 April to 31 March) and funds agreed must be claimed within the Financial Year they are granted.  A new Purchase Order Number is issued each year for use in that financial year.  Funds not claimed in the financial year they are granted cannot be carried forward to the next year and WILL NOT BE PAID.

o	Invoices for the months April to February must be submitted in arrears on a monthly basis to Kirklees Marketplace Invoices.
o	For the month of March the invoice must be submitted by the 23rd March to meet Year End Regulations.  
o	Any invoices received after the 23rd March for the current financial year will not be paid.
	
I agree to the conditions of the Early Years Access Funding
	
Setting Signature:
	Date:	
Print Name:
	Role: