Application for Solihull Early Years Inclusion and
High Needs Funding – Equipment only
Solihull’s Early Years Inclusion Fund Panel is made up of professionals from the 0-25 SEND Service, the Family Information Service, school nurseries and private and voluntary settings.
The Panel considers referrals for Early Years Inclusion and High needs Funding based on this criteria www.solihull.gov.uk/Children-and-family-support/localoffer/inclusion-fund
Please return completed forms to: Solihull Early Years Team, Council House, Manor Square, Solihull, West Midlands B91 3QB.
Alternatively this form can be scanned and emailed to eysendfundingapp@solihull.gov.uk. If you have any other queries regarding this form please call: 0121 704 6150.	

Name and address of Setting	

Postcode		Telephone No:		
Name and contact details of SENCo	
	
Name of child	
	Date of Birth		
Child’s address	

	Postcode (Solihull/Out of Borough)		
Date of admission to setting		Date child will start reception e.g. Sept XXXX		
Age in months
		Gender	Male
☐	Female
☐	
Please highlight the days and sessions the child attends:
Mon:	am/pm	Tues:	am/pm	Wed:	am/pm	Thurs:	am/pm    Fri:	am/pm	
Please outline equipment needed and summary of costings

	
Select the child’s Broad area of need as described in the SEND Code of Practice (please tick one box only)	
Communication and interaction	☐	Social, emotional and mental health	☐	
Cognition and learning	☐	Sensory and/or physical needs	☐	
Record of Diagnosis if known: Does the child have an EHCP?

	
Summary statements describing child’s learning and development 

	

For this section please tick the level of support required which is ‘additional to/different from’ what peers receive as part of your routine support for medical and health needs.
Medical and Health Needs	High	Med	Low	NA	

Have health/medical needs monitored by staff throughout session
	☐	☐	☐	☐	

Receive setting-based intervention advised by a medical practitioner/ health therapist
(eg physiotherapy programme, specialist feeding/ swallowing programme, receive medication)
	☐	☐	☐	☐	
Remain safe and well due to the implementation of medical care plan/medical emergency protocols advised by medical professionals
(NB if ticked the plan/protocols must be referenced in the health section of the child’s SEN and Early Support Plan)	☐	☐	☐	☐	

Name of Key Person:
		
Contact number:
		
Date:
		
Signature:
		
Name of 0-25 practitioner/ Area SENCo :

Contact number:
		
Email address:
		
Signature:
		
Please attach any recent reports from external services which support this application along with the equipment quote. Please ensure that the quote is for the full amount including VAT.

Any additional information can be added here.

	

PARENTAL CONSENT FORM
Any information provided will be used by the Early Years Inclusion Panel to help us make decisions about whether your child qualifies for additional funding to support their emerging SEND. Your information will be treated as confidential and stored in a secure way. It will only be shared with other council services and partner organisations to ensure our records are kept accurate.

We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. For further information about how we use your information please refer to the Council’s Privacy Statement on www.solihull.gov.uk 

Your records will be kept for 25 years for audit purposes and in the event we need to provide information about the service you have received.	
•	I confirm I understand why you want my information and I have had the opportunity to consider this.	Yes
☐	No
☐	
•	I agree that the information will be shared with other professionals who are already involved with my child, or other agencies that may become involved in the course of any support offered to my child. This will be done in accordance with Solihull Metropolitan Borough Council’s Information Sharing Protocols. This will only be information that is relevant and necessary and will only be shared with people who need that information at that time. 	Yes
☐	No
☐	
•	I understand I can opt out and withdraw my consent at any time by contacting the Early Years Team on 0121 704 6150 or via email at eyenquiries@solihull.gov.uk .	Yes
☐	No
☐	
•	I give my concern for you to record and hold my information for the purposes explained to me.	Yes
☐	No
☐	

Name of parent/carer:	…………………………….…………………………………
(please print)

Signature:			……………………………………………………………….

Email address:		………………………………………………………………..

Date:	………………………………