Application for free childcare for 2 year olds

Please complete the details below to find out if your child is eligible. We cannot process this application without the applicant’s date of birth and National Insurance/NASS number. Please only use full legal names when completing this form
Child details
First name
Middle names
Last name
Gender
MaleFemale
Date of birth

Applicant's details
Title
Relationship to child
First name
Last name
Address
Town
Postcode
Telephone
Email
Date of birth
National Insurance Number

(or National Asylum Support Service (NASS) reference number)
NASS number

Husband/ Wife/ Partner's details
(If child is co-parented)
Title
Relationship to child
First name
Last name
Postcode
Telephone
Date of birth
National Insurance Number

(or National Asylum Support Service (NASS) reference number)
NASS number

Criteria
Please select which criteria you meet:
Working Tax Credits and have annual gross earnings no more than £16,190Working Tax Credit ‘run-on’ – the payment you may receive for a further 4 weeks after they stop qualifying for Working Tax CreditIncome SupportIncome-based Job Seeker’s AllowanceIncome-related Employment or Support AllowanceChild Tax Credit – provided you have an annual income of no more than £16,190Support under Part 6 of the Immigration and Asylum Act 1999The ‘Guaranteed’ Element of the State Pension CreditChild receives disability living allowanceChild has a current statement of Special Educational Needs (SEN)or is on an Education,Health and Care Plan (EHC )planChild is looked after by a Local AuthorityChild has left the care of a Local Authority through special guardianship or an adoption or residence orderUniversal Credit

Agreement
I certify that the information given on this form is correct to the best of my knowledge and belief. I understand that the council may check with the Department of Work and Pensions (DWP) and / or HM Revenue and Customs regarding my eligibility for free childcare for 2 year olds and the Early Years Pupil Premium for 3 and 4 year olds. If you wish to withdraw your consent to a check being undertaken for Early Years Pupil Premium (EYPP) in the future, you can inform your childcare provider or write/email Blackpool Council. We may need to use this information for enquiries under Section 29.3 of the Data Protection Act – amended 1998 – Detection and Prevention of a crime.
Name
Date
Where did you hear about the Free childcare for 2 year olds offer ?
Nursery / ChildminderSchoolChildrens CentrePostcardRadio AdvertLocal NewspaperHealth VisitorFriend/FamilyOtherOther - text entry
Blackpool Council is the data controller for the personal information you have provided in this form. The council’s data protection officer can be contacted at DPA@blackpool.gov.uk.
Your personal information will be used to contact the Department of Work Pensions DWP and / or HM Revenue and Customs regarding your eligibility for free childcare for 2 year olds. We will also use the information to maintain statistical records of how many childcare places are being accessed, but we will anonymise your information.
We are allowed to ask for your personal information as the council has a statutory duty to provide up to 15 hours per week free entitlement to eligible families of 2 year olds.
We will contact you to ask if you have a childcare place. We may share your information with children’s centres and health visitors to encourage take up and to facilitate the 2 Year Old Progress Check. We will share your information with others if we are required to do so by law.
For further information about how Blackpool Council uses your personal information including your rights as a data subject, please see our website at www.blackpool.gov.uk/privacy

Application for free childcare for 2 year olds

Additional information

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