Application Form

1. Type of placement required

I am applying for (please select your prefered option)

(If, for any reason, we are unable to offer you a 2 year old place you will automatically be placed on our 3 year old waiting list.)

ADDITIONAL DOCUMENTS NEEDED: Child’s original birth certificate and proof of child’s address (e.g. medical card, child benefit letter, tenancy agreement etc.)

Please note that if you are applying for a 2 year old FREE place you also need to provide us with your confirmation letter from Southwark Council stating that you are eligible for a free 2 year old place..

2. Child's details

Child's First Name Child's Last Name Child's Age Child's Date of birth 01020304050607080910111213141516171819202122232425262728293031 010203040506070809101112 20202019201820172016201520142013201220112010
Child's Gender Home address Postcode

3. Parental Responsibility

First adult with parental responsibility

Full name Email Mobile Number Landline Number Relationship to child Gender Date of birth 01020304050607080910111213141516171819202122232425262728293031 010203040506070809101112 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319011900
National Insurance or NASS Number

Second adult with parental responsibility

Full name Email Mobile Number Landline Number Relationship to child Gender Date of birth 01020304050607080910111213141516171819202122232425262728293031 010203040506070809101112 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319011900
National Insurance or NASS Number

4. Siblings

Please give details of any siblings that attend/have applied or have attended Kintore Way:

Sibling One

Name of Sibling Date of birth 01020304050607080910111213141516171819202122232425262728293031 010203040506070809101112 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319011900
Year left Room/Class

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Sibling Two

Name of Sibling Date of birth 01020304050607080910111213141516171819202122232425262728293031 010203040506070809101112 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319011900
Year left Room/Class

5. Special Educational Needs

Does your child have any Special Educational Needs (including any speech and language concerns)?

If so, please give details (including names of therapists) below:

SEN Details

6. Medical Needs

Does your child have any medical and / or social needs?

If so, please give details below and attach any supporting documents to this form:

Medical or Social needs

7. Current Nursery

Does your child already attend a nursery?

If so, please give details below (please note: the government funded 15 hours for 2/3 year olds can only be taken advantage of in one nursery. Therefore if you accept a place at Kintore Way, you must not accept government-funded nursery education anywhere else):

Name of nursery already attending: Address of nursery already attending: Postcode

8. Preferences

Do you have a preferred room/class or key person you would like your child to have?

If so, please give details below:

Name of room/class preferred: Name of key person preferred:

9. Parent or Carer work/study hours

If applicable, how many hours per week are you / will you be working or studying?

1st Parental Responsibility:

Work/Study Hours per week 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

2nd Parental Responsibility:

Work/Study Hours per week 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

10. Benefits

Do you receive any of the following benefits?

Income Support
Income-based Job Seekers Allowance
Guarantee element of State Pension Credit (sole source)
Employment and Support Allowance
Child Tax Credit
Working Tax Credit
Support under Part VI of the Immigration and Asylum Act 1999
Child Benefit
Any other benefits:

11. Ethnic Background

Our ethnic background describes how we think of ourselves.

This may be based on many things including, for example, our skin colour, language, culture, ancestry or family history. Ethnic background is not the same as nationality or country of birth.

Please study the list below and select one box only to indicate your child’s ethnic background.

12. Language and Religion

First Parental Responsibility Home Language Second Parental Responsibility Home Language Child's prefered langauge / Main language spoken at home Religion (if any)

13. Home visits

If your child is offered a place, a home visit will be arranged with your key person before your child starts. Please indicate below if you do not speak English and would require an interpreter at your home visit:

Interpreter needed Yes/No Language needed

14. Anything else?

Is there anything else you would like to tell us?