Early Childhood Service
Inclusion Funding Application Form
This form must only be completed after you have spoken to your local Early Years and Childcare
Adviser and you have been advised to apply for funding. The completed application form must be
submitted at least 15 working days before the Funding Panel date for the application to be considered.
The form has been designed to be completed by typing into it as directed. The boxes will expand to
allow you to add as much detail as possible. Please refer to the guidance available at
www.westsussex.gov.uk/ecsgoodpractice (under the ‘Including all children’ heading) to ensure you
complete this form correctly.
Section A – to be completed by the setting
parents/carers
Child’s Details
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Child’s Full Legal
Name
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Child’s Date of Birth
Identified SEND
☐Yes ☐No
Is the child known to
EYPARM?
☐Yes ☐No
Does the setting
receive any funding
from an EHC Plan
relating to this child?
Does the child attend
another childcare
setting?
☐Yes ☐No
Date child started at
the setting
Has the setting been
in receipt of Disability
Access Fund (DAF)
for this child?
☐Yes ☐No
If yes, please provide
the setting name:
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Click here to enter a date.
in consultation with the child’s
Child’s Address
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School Start Date
Has an Education,
Health and Care Plan
(EHCP)
Is an Education,
Health and Care
(EHC) needs
assessment being
carried out?
Has an Early Help
Plan been initiated for
the child?
Click here to enter a date.
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
If attending another
☐Yes ☐No
setting, does the child
receive IF funding at
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that setting and at
what rate?
Is the child in receipt
☐Yes ☐No
of Disability Living
Allowance (DLA)?
☐Yes ☐No
If yes, please provide details of what the DAF was used for, and how
this has impacted on the child:
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Child’s Needs
Please describe the nature of the
child’s needs.
Please detail the potential
barriers to the child’s inclusion
within the setting.
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Examples of potential barriers
include practitioner knowledge,
practitioner confidence and the
physical environment.
Please summarise the strategies
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included in the individual plan
you have created for the child,
indicating how the child and their
parent’s/carer’s needs, wishes
and feelings are included in the
plan.
What training have you
completed and how will you use
it to provide ongoing support for
this child?
How do you plan to provide ongoing support for this child and
other children with similar needs
in the future?
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Regular attendance at INCO Networks, EYFS and other relevant
training is a condition of funding.
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Section B – to be completed by the setting
Setting Details
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Setting Name
Ofsted Reference
Number
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Setting Address
Setting Postcode
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Contact Name
Contact’s Job Role
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Contact Email
Contact Phone
Address
Number
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This should be your main
registration email address
Name of Early Years
and Childcare Adviser
Has your setting had
TSS Support in the
last 12 months?
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☐Yes ☐No
Session Details
Please list the times of
sessions that the child attends
and the number of
practitioners who are
supporting in the setting.
How many weeks a year does
the child attend for?
During the sessions the child
attends, please state the
number of children also in
attendance by age group.
Name of Setting’s
SENCO/INCO
If yes, what area of
TSS was it for?
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Choose an item.
If other, please state:
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Session Times
Monday
Tuesday
Wednesday
Thursday
Friday
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enter text.
Monday
Tuesday
Wednesday
Thursday
Friday
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Number of Practitioners
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How many weeks is the child’s
FE used over?
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0-2
2-3
3-5
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Are there any other children
attending your setting also in
receipt of inclusion funding?
If yes, please list the times of
sessions that the child attends
and the number of
practitioners who are
supporting in the setting.
Yes ☐
No☐
Session Times
Monday
Tuesday
Wednesday
Thursday
Friday
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Section C - Supporting Professionals’ Details
Professional One
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Name
Job role
Contact Address
Contact Phone
Number
Advice/strategies
given
Professional Two
Name
Contact Address
Contact Phone
Number
Advice/strategies
given
Professional Three
Name
Contact Address
Contact Phone
Number
Advice/strategies
given
Professional Four
Name
Contact Address
Contact Phone
Number
Advice/strategies
given
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Contact Postcode
Contact Email
Address
Number of Practitioners
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Choose an item.
If other, please state
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Job role
Contact Postcode
Contact Email
Address
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If other, please state
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Job role
Contact Postcode
Contact Email
Address
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If other, please state
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Job role
Contact Postcode
Contact Email
Address
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If other, please state
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Completion checklist and declaration
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Please note that applications will be returned if incomplete and/or missing essential
documents.
All applications must include the following. Please tick the boxes to confirm you have
submitted them alongside the application.
Progress Overview
☐
A recent Individual Plan with ☐
outcomes reviewed
Any appropriate outside agency ☐
A current Individual Plan
☐
information/strategies/advice
One Page Profile
☐
Other documentation
(please state)
Click here to enter
text.
Please tick to confirm you have included any of these additional documents if applicable.
Communication monitoring tool
☐
EYPARM Report
☐
STAR Observations
☐
Communication
Environment Development
Plan
☐
Signed
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Date
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The local authority has a duty to protect the public funds it administers, and to this end may
use the information you have provided on this form for the prevention and detection of fraud.
It may also share this information with other bodies responsible for auditing or administering
public funds for these purposes.
For further information, see www.westsussex.gov.uk/nfi
Once completed please email the application form and relevant documents to
[email protected] at least 15 working days before the published date
for Funding Panel (see West Sussex County Council website).
Page 4 | Updated April 2017 | This document is available online at www.westsussex.gov.uk/ecsgoodpractice