Fillable The Childcare Offer for Wales Application Form Gwynedd, (Conwy County Borough Council)

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The Childcare Offer for Wales Application Form Gwynedd, (Conwy County Borough Council)

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Page 1 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
The Childcare Offer for Wales – Application Form
Gwynedd, Anglesey & Conwy
This form is to apply for up to 20 hours of government-funded childcare that is in
addition to your 10 hours of Early Years Education Provision, and is available for
three and four year olds of working parents for up to 48 weeks of the year.
Please note some schools / settings in Conwy may offer more than 10 hours
Foundation Phase these additional hours will form part of the 30 hours offer
During the 39 weeks of school term time the offer will fund a maximum of 20 hours of
childcare in addition to the 10 hours of Early Years Education.
During up to 9 weeks of school holidays the offer will fund 30 hours of childcare.
(Please note: there are 13 weeks of school holidays during the school year)
Eligible children will be able to access the offer from the beginning of the term
following their third birthday until the September following their fourth birthday when
they begin full-time education.
All childcare settings chosen will have to be registered with the Care Inspectorate
Wales (CIW)
Parents are eligible for the government-funded childcare if at least one parent
resides in Gwynedd / Anglesey or Conwy and:
All parents, or co-habiting couples, in the household work the equivalent of at
least 16 hours at national living wage or national minimum wage.
(Parents will not to be eligible if they earn more than £100,000 per annum-
this is a per parent limit)
One parent is employed and one parent has substantial caring responsibilities
based on specific benefits received for caring;
Both parents are employed but one or both parents are temporarily away from
the workplace on parental, maternity, paternity or adoption leave;
Both parents are employed but one or both parents are temporarily away from
the workplace on statutory sick pay;
One parent is employed and one parent is disabled or incapacitated based on
receipt of specific benefits;
Please note: Making an application does not guarantee a childcare place.
Page 2 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Parents who would normally have met the income eligibility criteria for the
Childcare Offer but who don’t now as a result of Covid-19
Parents applying for the Offer will be considered eligible if they can evidence that
they would normally meet the earnings eligibility criteria for the Offer.
You will need to evidence that, as a result of Covid-19, your earnings in January /
February 2020 met the income eligibility criteria for the Offer but that you have seen
a reduction in income since then.
We will re-check the eligibility of parents who fall into this category at the end of
October. You will be granted an 8 week temporary exemption period (TEP) starting
on 1 November, if your income still does not meet the requirements for the Offer or is
not expected to meet the requirements from 1 November. Funding will cease at the
end of the TEP unless your income meets the relevant criteria.
Page 3 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 1 – Child’s Details
Legal Forename(s):
(as on birth certificate)
Legal Middle Name:
(as on birth certificate)
Legal Surname:
(as on birth certificate)
Date of Birth:
/
/
Gender:
Male ☐ Female ☐
Ethnicity:
Birth Certificate
Number:
Address:
Postcode:
What is your child’s
main language?
English ☐ Welsh ☐ Other ☐
If other, please specify:
I think my child may
have a health,
behaviour or
development issue
which may require extra
care or help
Yes ☐ No ☐ Not Sure ☐
Page 4 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Is your child currently under a Care Order?
No ☐
Is your child Looked After? (In Local Authority
Care)
No ☐
If yes, please provide the name of the corporate
parent
Has your child previously been Looked After? (e.g.
are they fostered or have they ever been
fostered?)
No ☐
If yes, please provide the name of the previous
corporate parent
Is the child a twin or triplet etc. (one of multiple
birth)?
No ☐
If yes, please complete a separate application form for each child.
Page 5 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 2 – Parent / Guardian Eligibility
Please tick all statements that apply to you.
All parents in my household work the equivalent of at least 16 hours
at national living wage or national minimum wage
☐
One parent is employed and one parent has substantial caring
responsibilities and receives benefits linked to their caring
responsibilities.
☐
Both parents are employed but one or both parents are temporarily
away from the workplace on parental, maternity, paternity or adoption
leave.
☐
Both parents are employed but one or both parents are temporarily
away from the workplace on statutory sick pay.
☐
One parent is employed and one parent is disabled or incapacitated
based on receipt of specific benefits.
☐
At least one parent resides within Gwynedd, Anglesey or Conwy
☐
Your application will not be considered unless the relevant boxes have been
ticked.
Page 6 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 3 – Parent / Legal Guardian Details
All details for parents, or co-habiting couples, in the household need to be accurately
included in this application form.
Incorrect information submitted may result in funded provision being
removed and / or funding being reclaimed.
Parent / Legal Guardian One
Parent / Legal Guardian Two
(If Applicable)
Forename:
Surname:
What is your
preferred language
of communication?
If other, please
specify
English ☐ Welsh ☐
Other ☐ If other, please
specify:
English ☐ Welsh ☐
Other ☐ If other, please
specify:
Relationship to the
child:
Date of Birth:
/
/
/
/
Telephone number:
Email:
Address:
Postcode:
Please note that if you are not the person responsible for payment of
Council Tax for the address given you will need to provide proof of residency.
Failure to attach details may result in a delay in the form being processed.
Page 7 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Parent / Legal Guardian One
Parent / Legal Guardian Two
What is your
ethnic group?
Please choose
one option that
best describes
your ethnic
group or
background
White
White
Welsh / English / Scottish /
Northern Irish / British
☐
Welsh / English / Scottish /
Northern Irish / British
☐
Irish
☐
Irish
☐
Gypsy or Irish Traveller
☐
Gypsy or Irish Traveller
☐
Any other White background,
please describe
☐
Any other White background,
please describe
☐
Mixed / Multiple ethnic groups
Mixed / Multiple ethnic groups
White and Black Caribbean
☐
White and Black Caribbean
☐
White and Black African
☐
White and Black African
☐
White and Asian
☐
White and Asian
☐
Any other Mixed / Multiple ethnic
background, please describe
☐
Any other Mixed / Multiple ethnic
background, please describe
☐
Asian / Asian British
Asian / Asian British
Indian
☐
Indian
☐
Pakistani
☐
Pakistani
☐
Bangladeshi
☐
Bangladeshi
☐
Chinese
☐
Chinese
☐
Any other Asian background,
please describe
☐
Any other Asian background,
please describe
☐
Black / African / Caribbean / Black
British
Black / African / Caribbean / Black
British
African
☐
African
☐
Caribbean
☐
Caribbean
☐
Any other Black / African /
Caribbean background, please
describe
☐
Any other Black / African /
Caribbean background, please
describe
☐
Other ethnic group
Other ethnic group
Arab
☐
Arab
☐
Any other ethnic group, please
describe
☐
Any other ethnic group, please
describe
☐
x
x
x
x
x
x
Page 8 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Parent / Legal Guardian One
Parent / Legal Guardian Two
Employer’s name:
Employer’s
address:
Telephone number:
Email:
2
nd
Employer’s
name (if applicable):
2
nd
Employer’s
address
(if applicable):
Telephone number:
Email:
How many hours a
week (including
overtime) do you
usually work?
Total annual Salary
(Please tick one)
Up to £5,199
☐
Up to £5,199
☐
£5,200 and up to £10,399
☐
£5,200 and up to £10,399
☐
£10,400 and up to £15,599
☐
£10,400 and up to £15,599
☐
£15,600 and up to £20,799
☐
£15,600 and up to £20,799
☐
£20,800 and up to £25,999
☐
£20,800 and up to £25,999
☐
£26,000 and up to £31,199
☐
£26,000 and up to £31,199
☐
£31,200 and up to £36,399
☐
£31,200 and up to £36,399
☐
£36,400 and up to £51,999
☐
£36,400 and up to £51,999
☐
£52,000 and above
☐
£52,000 and above
☐
The Gwynedd & Anglesey Childcare Unit may contact your employer
to verify the above details.
xxx
xx
xx
xxx
x
y
x
Page 9 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 4 – Childcare Provider Details
You may access the offer at a maximum of two registered childcare settings in
addition to your Foundation Phase Nursery setting in any given day.
Please provide details of the childcare provision you will be using - you must
state the exact number of funded hours you are applying for –
maximum of 20 hours during term time & 30 hours during school holidays.
If you are unsure please discuss with your childcare provider.
Name and Address of Childcare Provider 1
Name of Provider:
Address:
Hours of childcare applied
for per week:
Term Time
Hours of childcare applied
for per week:
School Holidays
Number of days of childcare
applied for per week:
Term Time
Number of days of childcare
applied for per week:
School Holidays
Language medium of
provision – English, Welsh,
Bilingual
Date childcare begins:
Date contract ends:
Name and Address of Childcare Provider 2
Name of Provider:
Address:
Hours of childcare applied
for per week:
Term Time
Hours of childcare applied
for per week:
School Holidays
Number of days of childcare
applied for per week:
Term Time
Number of days of childcare
applied for per week:
School Holidays
Language medium of
provision – English, Welsh,
Bilingual
Date childcare begins:
Date contract ends:
x
x
x
x
x
x
Page 10 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 5 – About the Child referred to in section 1.
We are collecting this information to help evaluate the accessibility of the
childcare offer.
Please tick any that are applicable.
I would like to
access
I currently
access
Welsh medium childcare - where Welsh is the
main day to day language of the setting.
(this includes Cylchoedd Meithrin)
☐
☐
Bilingual childcare where Welsh and English are
used side by side
☐
☐
English medium with some Bilingual elements -
English is the language of the majority of activities
and communication. The Welsh element is
introduced through activities such as songs,
stories and games, and greetings
☐
☐
English medium childcare - where English is the
main day to day language of the setting
☐
☐
My child has previously
accessed a Flying Start
Setting
Yes ☐ No ☐ Not Sure ☐
Do you intend for your child to attend, or is your child currently attending, ‘foundation
phase nursery’ provision, that is sometimes called ‘early years entitlement’? The
Foundation Phase is a developmental curriculum for three- to seven-year-olds in
Wales. (Your child might be accessing foundation phase nursery provision through
your local school, Cylch Meithrin, Playgroup, or Nursery).
My child currently attends for ………hours every week
☐
I intend for my child to attend Foundation phase nursery for …… hours
every week (if known)
☐
I do not intend for my child to attend Foundation phase nursery
☐
Page 11 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
How much do you currently spend on
childcare a month?
£
How easy or difficult do you find it to afford
childcare?
Very difficult
Somewhat difficult
Neither easy nor difficult
Somewhat easy
Very easy
☐
☐
☐
☐
☐
On average, how many hours per week do
family or friends look after your child,
unpaid, while you are working?
On average, how many hours per week do
you use childcare, paid, for your child while
you are working?
Page 12 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
Section 6 – Additional Documents
(We will accept scanned copies, or clear photographs taken by phone)
I confirm that I have included these documents to support my application.
All additional documents will be destroyed once your application has been assessed.
The Gwynedd & Anglesey Childcare Unit may ask you to supply original documents
to support your claim at any time during this childcare offer.
(Please note that without these documents we will not be able to
process your application)
Employed
Last three months’ wage slips for parent one
☐
Last three months’ wage slips for parent two (if applicable)
☐
Child’s Birth Certificate
☐
Current Council Tax Payment Form
☐
Self - Employed
Copy of Self-Assessment Tax Form for previous financial year –
parent one
☐
Copy of Self-Assessment Tax Form for previous financial year –
parent two (if applicable)
☐
Child’s Birth Certificate
☐
Current Council Tax Payment Form
☐
Evidence that one parent is in receipt of one of the following benefits
Incapacity Benefit
☐
Carers Allowance
☐
Severe Disablement Allowance
☐
Employment & Support Allowance
☐
National Insurance Credits on the grounds of incapacity for work or
limited capability for work
☐
Page 13 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
7. Parental Declarations
I confirm that:
By signing this application form I declare that all the information I have
given is correct. If it is found that any information I have given is incorrect
and I do not meet the criteria for the pilot, I understand that my child will
lose their place in the scheme immediately and further action may be taken
to recover the cost of the childcare;
All parents in my household work the equivalent of at least 16 hours at
national living wage or national minimum wage;
I will inform the Gwynedd & Anglesey Childcare Unit if my circumstances
change that may impact upon my eligibility for the offer.
I understand that:
By signing this application form I declare that all the information I have
given is correct. If it is found that any information I have given is incorrect
and I do not meet the criteria for the pilot, I understand that my child will
lose their place in the scheme immediately and further action may be taken
to recover the cost of the childcare.
The Gwynedd & Anglesey Childcare Unit will be checking my
documentation for eligibility and I may be asked to produce further evidence
of my eligibility. If I am found to be ineligible the offer of government-funded
childcare will be formally withdrawn.
The information that I provide will be used by the Gwynedd & Anglesey
Childcare Unit to compare my application with the eligibility criteria. It will
also be used for statistical analysis purposes. Information will be shared
with the Family Information Service and processed in accordance with the
Data Protection Act 1998 and any amendments to that Act.
I am entitled to a maximum of 30 hours of free childcare a week for up to 48
weeks of the year for my three / four year old. During school term time this
will comprise of 10 hours of Foundation Phase Nursery Provision and a
maximum of 20 hours of government-funded childcare.
The government-funded childcare places will be restricted to parents living
within Gwynedd, Anglesey & Conwy. If I do not live within these areas then I
am not eligible for the offer.
I will be asked to re-confirm that I am eligible for the childcare offer once
every three months/ during each school term.
It is the parents’ responsibility to find a childcare provider that meets their
needs. When signing a contract with a provider the parent is entering into a
legal contract, independent of Gwynedd, Anglesey & Conwy Council.
My government-funded childcare is not available until confirmed by
the Gwynedd & Anglesey Childcare Unit to me in a letter.
I have read the above and agree with the terms.
Parent’s name:
Parent’s signature:
Date:
Page 14 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
I understand that:
If I participate in the government-funded childcare offer I may be contacted by
researchers appointed by the Welsh Government and information collected from me
may be used in the following ways:
to measure how well Welsh Government and Local Authorities are
delivering their services to you and your child;
to support improvements to these services;
to allocate money to Local Authorities and others; or
to support wider research into the provision of services to you and your
child, or others;
to link data from this form to other data sources for the purpose of
evaluating the impact of the project on the individuals who take part.
The data sent to Welsh Government will not be used by them:
to take any action in relation to you or your child; nor
to identify you or your child in any reports.
The Data Protection Act gives individuals certain rights in respect of the personal
data held on them. Whilst not intending to be exhaustive, examples of these rights
include:
the right to ask for and receive copies of the personal data the Welsh
Government holds about you (you may have to pay a small fee for this),
although some information can sometimes be legitimately withheld
the right, in some circumstances, to prevent the processing of personal
data if doing so will cause damage or distress
the right to ask for wrong information to be put right
You also have the right to ask the Information Commissioner, who
enforces and oversees the Data Protection Act, to assess whether or
not the processing of your personal data is likely to comply with the
provisions of the Act.
If you have any further questions about how data about you (or your child) will be
used by Welsh Government, wish to prevent the processing of your personal data, or
if you have any concerns about the accuracy of personal data or wish to exercise any
of your rights under the Data Protection Act, please write to us using the details
below.
CP2, Crown Buildings
Cathays Park
Cardiff
CF10 3NQ
email: TalkChildcare@gov.wales
The Welsh Government’s Data Protection Officer can be contacted at Welsh
Government, Cathays Park, Cardiff, CF10 3NQ.
Email: DataProtectionOfficer@wales.gsi.gov.uk.
The Information Commissioners Office can be contacted on 01625 545745.
Page 15 of 15
Gwynedd & Anglesey Childcare Unit
V4 updated 01/08/2020
The Gwynedd & Anglesey Childcare Unit will inform you of the outcome of your
application by email within 20 working days of receipt of the application.
Your eligibility for funded childcare will begin after you receive your confirmation
letter.
Processing of your application will be delayed if you do not fully complete the
form or if incorrect supporting documentation is received.
Please return the completed application form and all the required additional
documents by email.
(We will accept scanned copies, or clear photographs taken by phone)
It is not possible at present to send the application form by post
e-mail: childcareoffer@gwynedd.llyw.cymru
Phone: 01248 352436
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The Childcare Offer for Wales Application Form Gwynedd, (Conwy County Borough Council)

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Completed 4 January 2021

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