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About your child

First name (as on birth certificate)* Middle name(s) (as on birth certificate) Family name (as on birth certificate)* Date of birth*

Gender*MaleFemale

Ethnicity* Address first line* Address second line Town* Postcode*

Select any of these statements which applies to your childThey are in public care or are fostered under an arrangement made by the Local AuthorityThey have known disabilities, additional needs or social problems (referred from another agency)They have siblings who previously attended the nursery or school

Has your child attended a 2 Year Old Nursery?* Where and dates attended?*

Is your child developing as you would expect? e.g. sight and hearing, sentences, vocabulary and intelligibilityYesNo

If 'no', please tell us your concerns What language(s) does your child speak?* Your child's GP* Health visitor details* Was your child born on their due date (please state how many weeks)*

About you

Please confirm you have parental responsibility for this child*I do

Mother's name* Father's name* Main contact best phone number* Main contact email address*

What education and childcare are you looking for?

Site*North Site - Buxton RoadSouth Site - Edinburgh Road

Select the options you are interested in.*Free 15 hours for all 3 to 4 year olds morning sessions (5 x 3-hour sessions)Free 15 hours for all 3 to 4 year olds afternoon sessions (5 x 3-hour sessions)Free 30 hours for eligible 3 to 4 year oldsPaid-for extra hours for 3 to 4 year olds

If applying for 30 hours - National Insurance number 30 hour eligibility code

School dinnerI wish to buy a school lunch for £2:40 each dayI will provide a packed lunch

Date of application* Signature* Select Time

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