The Childcare Offer for Wales – Application Form
Gwynedd, Anglesey & Conwy

This form is to apply for up to 20 hours of government-funded childcare that is in addition to your 10 hours of Early Years Education Provision, and is available for three and four year olds of working parents for up to 48 weeks of the year.
Please note some schools / settings in Conwy may offer more than 10 hours Foundation Phase these additional hours will form part of the 30 hours offer
During the 39 weeks of school term time the offer will fund a maximum of 20 hours of childcare in addition to the 10 hours of Early Years Education.
During up to 9 weeks of school holidays the offer will fund 30 hours of childcare.
(Please note: there are 13 weeks of school holidays during the school year)

Eligible children will be able to access the offer from the beginning of the term following their third birthday until the September following their fourth birthday when they begin full-time education.
All childcare settings chosen will have to be registered with the Care Inspectorate Wales (CIW)

Parents are eligible for the government-funded childcare if at least one parent resides in Gwynedd / Anglesey or Conwy and:
•	All parents, or co-habiting couples, in the household work the equivalent of at least 16 hours at national living wage or national minimum wage.
(Parents will not to be eligible if they earn more than £100,000 per annum- this is a per parent limit)
•	One parent is employed and one parent has substantial caring responsibilities based on specific benefits received for caring;
•	Both parents are employed but one or both parents are temporarily away from the workplace on parental, maternity, paternity or adoption leave;
•	Both parents are employed but one or both parents are temporarily away from the workplace on statutory sick pay;
•	One parent is employed and one parent is disabled or incapacitated based on receipt of specific benefits;

Please note: Making an application does not guarantee a childcare place.

Parents who would normally have met the income eligibility criteria for the Childcare Offer but who don’t now as a result of Covid-19
Parents applying for the Offer will be considered eligible if they can evidence that they would normally meet the earnings eligibility criteria for the Offer. 
You will need to evidence that, as a result of Covid-19, your earnings in January /  February 2020 met the income eligibility criteria for the Offer but that you have seen a reduction in income since then.
We will re-check the eligibility of parents who fall into this category at the end of October. You will be granted an 8 week temporary exemption period (TEP) starting on 1 November, if your income still does not meet the requirements for the Offer or is not expected to meet the requirements from 1 November. Funding will cease at the end of the TEP unless your income meets the relevant criteria.

Section 1 – Child’s Details
Legal Forename(s):
(as on birth certificate)		
Legal Middle Name:
(as on birth certificate)		
Legal Surname:
(as on birth certificate)		
Date of Birth:

/	

/	

	

	
Gender:
	Male  ☐             Female ☐	
Ethnicity:
		
Birth Certificate Number:
		
Address: 

	

	
Postcode:
		
What is your child’s main language?	English  ☐      Welsh ☐    Other     ☐ 
If other, please specify:

	
I think my child may have a health, behaviour or development issue which may require extra care or help 
	Yes  ☐           No ☐         Not Sure  ☐

     	

Is your child currently under a Care Order?	  Yes  ☐	  No  ☐	
Is your child Looked After? (In Local Authority Care) 
	  Yes  ☐	  No  ☐	
If yes, please provide the name of the corporate parent		
Has your child previously been Looked After? (e.g. are they fostered or have they ever been fostered?)	  Yes  ☐	  No  ☐	
If yes, please provide the name of the previous corporate parent		

Is the child a twin or triplet etc. (one of multiple birth)?	  Yes  ☐	  No  ☐	

If yes, please complete a separate application form for each child.

Section 2 – Parent / Guardian Eligibility
Please tick all statements that apply to you.
All parents in my household work the equivalent of at least 16 hours at national living wage or national minimum wage	☐	
One parent is employed and one parent has substantial caring responsibilities and receives benefits linked to their caring responsibilities.	☐	
Both parents are employed but one or both parents are temporarily away from the workplace on parental, maternity, paternity or adoption leave. 	☐	
Both parents are employed but one or both parents are temporarily away from the workplace on statutory sick pay.	☐	
One parent is employed and one parent is disabled or incapacitated based on receipt of specific benefits.	☐	

At least one parent resides within Gwynedd, Anglesey or Conwy
	☐	

Your application will not be considered unless the relevant boxes have been ticked.

Section 3 – Parent / Legal Guardian Details
All details for parents, or co-habiting couples, in the household need to be accurately included in this application form.
Incorrect information submitted may result in funded provision being
removed and / or funding being reclaimed. 

	Parent / Legal Guardian One	Parent / Legal Guardian Two
(If Applicable)	
Forename:
			
Surname:
			
What is your preferred language of communication?
If other, please specify	English  ☐    Welsh ☐        Other     ☐ If other, please specify:
     
	English  ☐  Welsh ☐        Other     ☐ If other, please specify:
     	
Relationship to the child:			
Date of Birth:

/	

/	

	

		
	
/	

/	

	

	
Telephone number:
			
Email:

Address:

	

		
Postcode:

Please note that if you are not the person responsible for payment of
Council Tax for the address given you will need to provide proof of residency.
Failure to attach details may result in a delay in the form being processed.

	Parent / Legal Guardian One	Parent / Legal Guardian Two	
What is your ethnic group? 

Please choose one option that best describes your ethnic 
group or background	White	White	
	Welsh / English / Scottish / Northern Irish / British	☐	Welsh / English / Scottish / Northern Irish / British	☐	
	Irish	☐	Irish	☐	
	Gypsy or Irish Traveller	☐	Gypsy or Irish Traveller	☐	
	Any other White background, please describe

	☐	Any other White background, please describe

	☐	
	Mixed / Multiple ethnic groups 	Mixed / Multiple ethnic groups	
	White and Black Caribbean 	☐	White and Black Caribbean 	☐	
	White and Black African	☐	White and Black African	☐	
	White and Asian	☐	White and Asian	☐	
	Any other Mixed / Multiple ethnic background, please describe

	☐	Any other Mixed / Multiple ethnic background, please describe
	☐	
	Asian / Asian British	Asian / Asian British	
	Indian	☐	Indian	☐	
	Pakistani	☐	Pakistani	☐	
	Bangladeshi	☐	Bangladeshi	☐	
	Chinese	☐	Chinese	☐	
	Any other Asian background, please describe

	☐	Any other Asian background, please describe

	☐	
	Black / African / Caribbean / Black British	Black / African / Caribbean / Black British	
	African	☐	African	☐	
	Caribbean	☐	Caribbean	☐	
	Any other Black / African / Caribbean background, please describe

	☐	Any other Black / African / Caribbean background, please describe

	☐	
	Other ethnic group 	Other ethnic group	
	Arab	☐	Arab	☐	
	Any other ethnic group, please describe
	☐	Any other ethnic group, please describe	☐	

	Parent / Legal Guardian One	Parent / Legal Guardian Two	
Employer’s name:
			
Employer’s address:

Telephone number:
			
Email: 
			
2nd Employer’s name (if applicable):			
2nd Employer’s address 
(if applicable):

			
Telephone number:
			
Email: 
			
How many hours a week (including overtime) do you usually work? 			
Total annual Salary (Please tick one)	Up to £5,199	☐	Up to £5,199	☐	
	£5,200 and up to £10,399	☐	£5,200 and up to £10,399	☐	
	£10,400 and up to £15,599	☐	£10,400 and up to £15,599	☐	
	£15,600 and up to £20,799	☐	£15,600 and up to £20,799	☐	
	£20,800 and up to £25,999	☐	£20,800 and up to £25,999	☐	
	£26,000 and up to £31,199	☐	£26,000 and up to £31,199	☐	
	£31,200 and up to £36,399	☐	£31,200 and up to £36,399	☐	
	£36,400 and up to £51,999	☐	£36,400 and up to £51,999	☐	
	£52,000 and above	☐	£52,000 and above	☐	
The Gwynedd & Anglesey Childcare Unit may contact your employer to verify the above details.

Section 4 – Childcare Provider Details
You may access the offer at a maximum of two registered childcare settings in addition to your Foundation Phase Nursery setting in any given day. 
Please provide details of the childcare provision you will be using - you must state the exact number of funded hours you are applying for – 
maximum of 20 hours during term time & 30 hours during school holidays.
If you are unsure please discuss with your childcare provider.

Name and Address of Childcare Provider 1
Name of Provider:
		
Address:

Hours of childcare applied for per week: 
Term Time		Hours of childcare applied for per week:
School Holidays		
Number of days of childcare applied for per week: 
Term Time		Number of days of childcare applied for per week:
School Holidays		
Language medium of provision – English, Welsh, Bilingual		
Date childcare begins:
		
Date contract ends:		

Name and Address of Childcare Provider 2
Name of Provider:
		
Address:	

Hours of childcare applied for per week: 
Term Time		Hours of childcare applied for per week:
School Holidays		
Number of days of childcare applied for per week: 
Term Time		Number of days of childcare applied for per week:
School Holidays		
Language medium of provision – English, Welsh, Bilingual		
Date childcare begins:
		
Date contract ends:		

Section 5 – About the Child referred to in section 1.

We are collecting this information to help evaluate the accessibility of the childcare offer. 
Please tick any that are applicable.

	I would like to access	I currently access	
Welsh medium childcare - where Welsh is the main day to day language of the setting. 
(this includes Cylchoedd Meithrin)	☐	☐	
Bilingual childcare  where Welsh and English are used side by side	☐	☐	
English medium with some Bilingual elements - English is the language of the majority of activities and communication. The Welsh element is introduced through activities such as songs, stories and games, and greetings	☐	☐	
English medium childcare - where English is the main day to day language of the setting	☐	☐	
 
My child has previously accessed a Flying Start Setting	Yes  ☐           No ☐         Not Sure     ☐

Do you intend for your child to attend, or is your child currently attending, ‘foundation phase nursery’ provision, that is sometimes called ‘early years entitlement’?  The Foundation Phase is a developmental curriculum for three- to seven-year-olds in Wales. (Your child might be accessing foundation phase nursery provision through your local school, Cylch Meithrin, Playgroup, or Nursery).	
My child currently attends for ………hours every week	☐	
I intend for my child to attend Foundation phase nursery for …… hours every week (if known)	☐	
I do not intend for my child to attend Foundation phase nursery	☐	

How much do you currently spend on childcare a month?	£	
How easy or difficult do you find it to afford childcare?	Very difficult
Somewhat difficult
Neither easy nor difficult
Somewhat easy
Very easy 	☐
☐
☐      
☐
☐
	
On average, how many hours per week do family or friends look after your child, unpaid, while you are working?		
On average, how many hours per week do you use childcare, paid, for your child while you are working?		

Section 6 – Additional Documents 
(We will accept scanned copies, or clear photographs taken by phone)
I confirm that I have included these documents to support my application.
All additional documents will be destroyed once your application has been assessed.
The Gwynedd & Anglesey Childcare Unit may ask you to supply original documents to support your claim at any time during this childcare offer.
(Please note that without these documents we will not be able to process your application)
Employed

Last three months’ wage slips for parent one	☐	

Last three months’ wage slips for parent two (if applicable)	☐	

Child’s Birth Certificate	☐	

Current Council Tax Payment Form	☐	

Self - Employed
Copy of Self-Assessment Tax Form for previous financial year – 
parent one	☐	
Copy of Self-Assessment Tax Form for previous financial year – 
parent two (if applicable)	☐	

Child’s Birth Certificate	☐	

Current Council Tax Payment Form	☐	

Evidence that one parent is in receipt of one of the following benefits

Incapacity Benefit	☐	

Carers Allowance	☐	

Severe Disablement Allowance	☐	

Employment & Support Allowance	☐	
National Insurance Credits on the grounds of incapacity for work or limited capability for work
	☐	

7. Parental Declarations	
I confirm that:
•	By signing this application form I declare that all the information I have given is correct. If it is found that any information I have given is incorrect and I do not meet the criteria for the pilot, I understand that my child will lose their place in the scheme immediately and further action may be taken to recover the cost of the childcare;
•	All parents in my household work the equivalent of at least 16 hours at national living wage or national minimum wage;
•	I will inform the Gwynedd & Anglesey Childcare Unit if my circumstances change that may impact upon my eligibility for the offer.
	
I understand that:
•	By signing this application form I declare that all the information I have given is correct. If it is found that any information I have given is incorrect and I do not meet the criteria for the pilot, I understand that my child will lose their place in the scheme immediately and further action may be taken to recover the cost of the childcare.
•	The Gwynedd & Anglesey Childcare Unit will be checking my documentation for eligibility and I may be asked to produce further evidence of my eligibility. If I am found to be ineligible the offer of government-funded childcare will be formally withdrawn.
•	The information that I provide will be used by the Gwynedd & Anglesey Childcare Unit to compare my application with the eligibility criteria. It will also be used for statistical analysis purposes. Information will be shared with the Family Information Service and processed in accordance with the Data Protection Act 1998 and any amendments to that Act.  
•	I am entitled to a maximum of 30 hours of free childcare a week for up to 48 weeks of the year for my three / four year old. During school term time this will comprise of 10 hours of Foundation Phase Nursery Provision and a maximum of 20 hours of government-funded childcare.   
•	The government-funded childcare places will be restricted to parents living within Gwynedd, Anglesey & Conwy. If I do not live within these areas then I am not eligible for the offer.
•	I will be asked to re-confirm that I am eligible for the childcare offer once every three months/ during each school term.
•	It is the parents’ responsibility to find a childcare provider that meets their needs. When signing a contract with a provider the parent is entering into a legal contract, independent of Gwynedd, Anglesey & Conwy Council. 
•	My government-funded childcare is not available until confirmed by the Gwynedd & Anglesey Childcare Unit to me in a letter.

I have read the above and agree with the terms.	
Parent’s name: 		
Parent’s signature: 		
Date:		
I understand that:
If I participate in the government-funded childcare offer I may be contacted by researchers appointed by the Welsh Government and information collected from me may be used in the following ways:

•	to measure how well Welsh Government and Local Authorities are delivering their services to you and your child;
•	to support improvements to these services;
•	to allocate money to Local Authorities and others; or
•	to support wider research into the provision of services to you and your child, or others;
•	to link data from this form to other data sources for the purpose of evaluating the impact of the project on the individuals who take part. 

The data sent to Welsh Government will not be used by them:
•	to take any action in relation to you or your child; nor
•	to identify you or your child in any reports.

The Data Protection Act gives individuals certain rights in respect of the personal data held on them. Whilst not intending to be exhaustive, examples of these rights include:
•	the right to ask for and receive copies of the personal data the Welsh Government holds about you (you may have to pay a small fee for this), although some information can sometimes be legitimately withheld 
•	the right, in some circumstances, to prevent the processing of personal data if doing so will cause damage or distress
•	the right to ask for wrong information to be put right
•	You also have the right to ask the Information Commissioner, who enforces and oversees the Data Protection Act, to assess whether or not the processing of your personal data is likely to comply with the provisions of the Act. 

If you have any further questions about how data about you (or your child) will be used by Welsh Government, wish to prevent the processing of your personal data, or if you have any concerns about the accuracy of personal data or wish to exercise any of your rights under the Data Protection Act, please write to us using the details below.

CP2, Crown Buildings
Cathays Park
Cardiff
CF10 3NQ
email: TalkChildcare@gov.wales

The Welsh Government’s Data Protection Officer can be contacted at Welsh Government, Cathays Park, Cardiff, CF10 3NQ. 
Email: DataProtectionOfficer@wales.gsi.gov.uk.

The Information Commissioners Office can be contacted on 01625 545745.
	
The Gwynedd & Anglesey Childcare Unit will inform you of the outcome of your application by email within 20 working days of receipt of the application.
Your eligibility for funded childcare will begin after you receive your confirmation letter.
Processing of your application will be delayed if you do not fully complete the form or if incorrect supporting documentation is received.
Please return the completed application form and all the required additional documents by email.
(We will accept scanned copies, or clear photographs taken by phone)
It is not possible at present to send the application form by post

e-mail: childcareoffer@gwynedd.llyw.cymru

Phone:  01248 352436