Current Start Preview Complete Your details Name Job Title Child Details Child name Child Date of Birth Which fund are you applying for: SEN Inclusion Funding Disability Access Funding Type of SEN Inclusion Funding 9 month SEN Inclusion Funding 2 year SEN Inclusion Funding 3-4 year SEN Inclusion Funding Type of Disability Access Funding 9 month Disability Access Funding 2 year Disability Access Funding 3-4 year Disability Access Funding Parent details Name Parent name Title Title - Select -MissMsMrMrsDrOther…- Select -▾- Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Parent address First line of address Second line of address City/Town Postcode Contact Contact details Email Phone number School/Setting details School/Setting Name SENCo Name SENCo Email Address For finance purposes please confirm the registered Company Name When did the child start attending the setting Entitlement 15 hours 30 hours Days the child attends the setting Monday Tuesday Wednesday Thursday Friday Hours attending each day Monday Tuesday Wednesday Thursday Friday Does the child attend for Term time only - Select -YesNo- Select -▾- Select -YesNo Are the hours stretched - Select -YesNo- Select -▾- Select -YesNo Is the child on a modified timetable? - Select -YesNo- Select -▾- Select -YesNo Is the child in receipt of Disability Living Allowance (DLA)? - Select -YesNo- Select -▾- Select -YesNo Please supply DLA Reference number Is there a SNEY/SIS Keyworker involved - Select -YesNo- Select -▾- Select -YesNo Please give name of SNEY/SIS keyworker Details of other agencies involved Documents required to support the application Upload function for most recent APDR cycle One file only.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Upload function for Costed Provision Map One file only.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Upload function for SNEY / SIS report One file only.64 MB limit.Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Quote for specialist equipment For example equipment advised by a specialist professional from an external supplier. Declaration details I confirm that I have shared this form with the child’s parents/carers and understand that the parents will receive an email confirmation that an application has been made. I confirm that I have read and understood the guidance notes and that I accept the conditions attached to any grant made. I confirm that this application is accurate, and any funding granted will be used for the purposes indicated. I am aware that if the child leaves the setting, any resources and/or equipment purchased with this funding will be transferred to the child’s new school (or to the Gem Centre if the equipment was loaned or a new school has not been arranged yet). I am aware that if a child’s EHCP is made final then Inclusion funding will cease. I understand that I may be allocated a percentage of the funding applied for, this is at the discretion of the panel. 21506
