Nursery Application Form

Full Legal Name of Child *

First Name Middle Name Last Name

Preferred First Name if Different

Gender *

Male Female

Date of Birth *

/ DD / MM YYYY

NHS Number *

10 digits

Ethnicity *

Home Language *

Religion *

Address of Child *

Street Address
Street Address Line 2
Town
Post Code	Country

Name of Early Years setting / Preschool your child attends or has attended *

e.g. Sunbeams, childminder, none etc

Special Education Needs - Does your child have a Statement of Special Educational Needs or an Educational Health and Care Plan (EHCP) ? If 'yes' please provide evidence. *

Yes No

At risk - Is your child, or a sibling of your child, subject of an inter-agency child protection plan and been placed on the Child Protection Register ? If 'yes' please provide evidence. *

Yes No

Child in Public Care - Is your child looked after, or was previously looked after and now is adopted, or with a Care Arrangement or Special Guardianship Order ? If 'yes' please provide evidence. *

Yes No

Social or Medical Reasons - Do you have a particular medical or social need to go to this school that another school cannot provide ? If 'yes' please provide evidence. *

Yes No

Does a sibling attend Broom Barns Primary School ? *

Yes No

Sibling's full name.

HMRC Code - the first 15 hours of which would be Broom Barns Nursery.

Other Relevant Information.

Medical conditions, allergies etc.

Full Name of Parent / Carer (priority 1) *

Title First Name Middle Name Last Name

Date of Birth of Parent *

- DD - MM YYYY

Relationship to Child ? *

Mother, Father, Carer etc.

National Insurance Number of Parent *

Address (if different from above)

Street Address
Street Address Line 2
Town	County
Post Code	Country

Mobile Phone number *

Home Phone Number *

Please include area code

Email Address *

A copy of the completed form will be sent to this email address.

NASS

National Asylum Support Service Number if applicable.

Second parent/carer? *

Yes No

Parent / Carer Name (Priority 2) *

Title First Name Middle Name Last Name

Date of Birth *

- DD - MM YYYY

Relationship to Child *

National Insurance Number of Parent *

Address (if different from above)

Street Address
Street Address Line 2
Town	County
Post Code	Country

Mobile Phone number *

Home Phone Number *

Please include area code

Email Address *

NASS

National Asylum Support Service Number is applicable.

DECLARATION

The information I have given on this form is complete and accurate. I understand that my personal information will be held securely and will be used only for local authority purposes.

I agree to Broom Barns School using this information to consider my application for a nursery place. I understand that if any part of this completed application for is found false the offer of a place will be withdrawn.

I understand that the completion of an application does not guarantee a place in nursery class.

I understand that, if offered a place in the nursery class, I have to apply separately for a place in reception (Primary).

I understand I must provide evidence at the time of application if I have answered ‘YES’ to any of the criteria overleaf e.g. SEN, Medical reasons etc.

I agree to complete, in full, and return a Nursery Declaration Form if my child is offered a place at Broom Barns Nursery.

DATA PROTECTION
In accordance with General Data Protection Regulation and current Data Protection Act, the school has a duty to protect this information and to keep it up to date. The school is required to share some of the data with the Local Authority and with the DfE.

Privacy Notice
In completing this application form you should refer to our Privacy Notice for Parents/Carers. The personal information collected on this form will be processed to manage your application in accordance with our Data Protection Policy.

Privacy Notice

I understand and I authorise Broom Barns Primary School to claim free entitlement funding as agreed on behalf of my child and give my consent. (This information is used to apply for funding on Hertfordshire Funding Database when your child becomes eligible). *

YES

I have read and agree with our Parent Privacy Notice. *

YES

I confirm that the details above are correct to the best of my knowledge. *

YES

Signature *

Broom Barns Nursery Application Form

About Your Child

Parent / Carer Details