Parental Contract for the Early Years Free Entitlement - 2, 3 and 4 year olds – 22/23
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3 & 4 Year Olds Only: All children are entitled to 15 Universal free hours from the term after the child’s 3 rd birthday
If a family apply to HMRC and are eligible, they will also be eligible to 15 Extended free hours , this could then make a
total of 30 free funded hours
Please note this form is mandatory and must be completed before your Early Years Provider can claim the Free
Entitlement for your child
Please put your child’s full name as shown on his/her birth certificate. Do not include nicknames or shortened
names.
Child’s details:
Child’s legal surname: _________________________ Child’s legal forename: _________________________
Name by which the child is known (if different from above): Gender: Male / Female
___________________________________
Date of Birth: ________________________________
Address: __________________________________
Ethnic Code (see list below): _____________________
_________________________________________
Postcode: ________________________________ Extended Entitlement Validity Code for 3 and 4 year old
children only:
Documentary proof of DOB Type (e.g. Birth Certificate, _______________________________
Passport): ________________________________
Date document recorded: ____________________ Parent/carer National Insurance or NASS Number:
Document recorded by: _____________________ ___________________________________________
Ethnic Codes:
WBRI White British APKN Asian or Asian British, Pakistani
WIRI White Irish ABAN Asian or Asian British, Bangladeshi
WIRT Traveller of Irish Hertitage AOTH Asian or Asian British, any other Asian background
WROM Gypsy/Roma BCRB Black or Black British, Caribbean
WOTH White, any other White background BACFR Black or Black British, African
MWBC Mixed, White and Black Caribbean BOTH Black or Black British, any other Black background
MWBA Mixed, White and Black African CHNE Chinese
MWAS Mixed, White and Asian OOTH Any other ethnic background
MOTH Mixed, any other mixed background REFU Did not wish to be recorded
AIND Asian or Asian British, Indian NOBT Not obtained
Has your child been at a childcare provider previously accessing their free entitlement, if so, please note below:
__________________________________________________________________________________________________
Applies to 3 and 4 year olds only:
Is your child eligible for Early Years Pupil Premium (EYPP): Yes / No (please delete as appropriate)
EYPP is an additional sum of money paid to childcare providers for children of families in receipt of certain benefits. This
funding will be used to impact positively on your child’s progress and development by improving the teaching, learning,
facilities and resources.
Children whose parents/carers receive one of the following benefits will generate EYPP for their provider:
• Income Support (IS) Child Tax Credit except if you meet ANY of the following
• Income-based (not contribution based) Job Seeker’s criteria:
Allowance (IBJSA) i) entitled to Working Tax Credit (regardless of income)
• The Guarantee element of the State Pension Credit ii) have an annual income in excess of £ 16,190
• Income-related employment and support allowance
• Or financially supported by NASS (National Asylum
Support Service)
If you believe your child may qualify for EYPP please provide the following information for the main benefit claimant to
enable the Local Authority to confirm eligiblity:
Parent/carer legal surname: ________________________ Parent/carer legal first name: __________________________
(these names should be the same as your benefits record)
Parent/carer date of birth: ________________________ Parent/carer National Insurance/NASS Number:
Parent/carer signature: ________________________ ___________________________________
Is your child eligible and in receipt of Disability Living Allowance (DLA): Yes / No (please delete as appropriate)
If your child is in receipt of DLA and is splitting their free entitlement across two or more providers please nominate below
the main setting where the Local Authority should pay the Disability Access Funding (DAF):
Name of Provider: ______________________________________________________
Declaration I (name): ______________________________________________________ confirm that the information I
have provided above is accurate and true. In addition, I agree that the information I have provided can be shared with
the Local Authority and HM Revenue and Customs, who will access information from other government departments to
confirm my child’s eligibility and enable this provider to claim the DAF on behalf of my child.
Print Name: ______________________________________________________________
Signed: ___________________________ Date: ___________________________
Applies to 2, 3 and 4 year olds
• You need to complete a Parental Contract with each provider your child attends for their Free Entitlement in order
to ensure that funding is paid fairly between them.
• The Government require parents to select the provider where you wish your child to continue to receive the
Universal 15 Hours should your child no longer meet the criteria to access the Extended 15 Hours.
• Select Universal (U) against the provider(s) providing upto 15 hours of Free Entitlement available to all eligible 2,
3 and 4 year olds.
• Select Extended (E) against the provider(s) providing upto 15 hours of Free Entitlement available to eligible 3 and
4 year olds.
This Contract starts from (date): _______________________________________________
Please enter total free entitlement hours attended per Total Number of
(Universal)
(Extended)
Setting day number weeks per
E
Name(s) of hours year (e.g.
MON TUES WEDS THURS FRI per week 38 or
51/52)
Total
Daily
Free
Hours
Attended
DECLARATION:
I confirm that the information I have provided on this Parental Contract is accurate and true. I understand and agree to
the conditions set out in this Contract and I authorise the provider(s) named above to claim the free entitlement funding
as agreed on behalf of my child.
Parent/Carer/Guardian with legal responsibility Childcare Provider
Signed Signed
Print Name Print Name
Date Date
FOR CHILDCARE PROVIDER USE ONLY:
Amendment to Parental Contract Form, please complete as appropriate.
Parent/carer name:
Date change takes effect:
Change of free entitlement hours:
Please enter total free entitlement hours Total Number of
(Universal)
(Extended)
Setting attended per day number weeks per
E
Name(s) of hours year (e.g.
MON TUES WEDS THURS FRI per week 38 or
51/52)
Total Daily Free
Hours
Attended
Other changes i.e. change of address:
I confirm that the information I have provided on this Amendment Form is accurate and true.
Parent/Carer/Guardian Childcare Provider
Signed Signed
Print Name Print Name
Date Date
