Children and Families (Wales) Measure 2010
Application to register as a day care provider

Mae'r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in  
                           Welsh

You need to be aware that from 1 April 2016 the Children and Families (Wales) Measure 2010, the Child Minding and Day Care Regulations and the National Minimum Standards for Regulated Childcare will be amended.  Find out how these changes may affect you

Before completing your application please familiarise yourself with the legislation below: 

•	Part 2 of the Children and Families (Wales) Measure 2010
•	The Child Minding and Day Care (Wales) Regulations 2010
•	The Child Minding and Day Care (Wales) (Amendment) Regulations 2016
•	The Regulation of Child Minding and Day Care (Wales) Order 2016
•	The Child Minding and Day Care (Disqualification) (Wales) Regulations 2010
•	The Child Minding and Day Care Exceptions (Wales) Order 2010
•	The Child Minding and Day Care Exceptions (Wales) Order 2016
•	National Minimum Standards for Regulated Child Care

The application form is divided into two parts. Both parts must be completed in full.

Important:
You are required to present a current DBS certificate (ie.no older than three months since date of issue) to support your application. This must be the original certificate and not a copy.

Where possible you should obtain one via your employer or umbrella body. Where this is not possible you may contact Care Inspectorate Wales on 0300 7900 126 and an advisor will give you details about how to do this. 

Guidance for applicants is available on our website www.careinspectorate.wales   and this will provide you with step-by-step guidance on completing your form. 

A checklist of additional documents that must be submitted with the application is included at the end of the application form.  

Details of the proposed service
Name and address of proposed service: 	     	
Post code:	     	

Telephone number:	     	

E-Mail address of the proposed service:	     

Fax number (if any), of the premises where the children are to be looked after:
(Paragraph 26, Schedule 2)	     	

Date of establishment of the service or proposed date:	      (dd/mm/yyyy)	

Language provision of proposed service                                                          
(please tick one box only)	
Welsh
	
English
	
Bilingual

	

Preferred language of inspection 
Please note that Welsh medium services will normally be assigned a Welsh speaking inspector to carry out your inspection so that they will be able to speak with people who use your service. 

For English medium and bilingual services only
Welsh
	
English

If your application is successful and you intend to provide an English medium or bilingual service, in which language would you like your inspection to be carried out?  
(please tick one box only)	

Language of published inspection report
In line with our publication policy, all inspection reports for Welsh and bilingual services are published in Welsh and English on our website. For English medium services we publish in English only unless requested.   

For English medium services only 
If your application is successful and you intend to provide 
an English medium service, please tick the box if you will      
also require your reports to be published in Welsh?       	

Will you be providing child care via a funded programme (eg. ‘Flying Start’, ‘Foundation Phase’)?     
                                                                                        Yes           No  
If ‘Yes’ please provide details below:
     

Type of service you are applying to register:

                     Full day care 	
	Sessional day care 	
	Crèche	
	Out of school care	
	Open access play provision	

Are you applying to register as an:

	Individual?		Organisation?	

“Organisation” means a body corporate or an unincorporated association (Regulation 2(1))

If you are an individual applicant please complete Section A below.

If you are an organisation please go straight to Section B.

If a ‘Person in Charge’ (PIC) is to be appointed, Section C must be completed.

All applicants must complete Sections D, E, and F within Part 1 of the application and Part 2 of the application including Section G.

About you, the care you want to provide, your premises and information about other persons who will work with you or who may live or work on the premises

Part 1

Section A: Application made by an individual
Details asked for in this section are required under the Child Minding and Day Care (Wales) Regulations 2010 Schedule 2, Part 2, Paragraph 22 as amended by the Child Minding and Day Care (Wales)(Amendment) Regulations 2016.
A1. This section should be completed by each individual who is proposing to be registered to provide the service and you should make as many copies of this section as required before you complete the form. If this application is being made by an organisation, please move to Section B
Title:	Mr:       Mrs:       Ms:       Miss:         Other (Please specify):      	

Your full name:	     

Any aliases and former names:	     

Date of birth:
(dd/mm/yyyy)	     	

Your address:	     	

Post code:	     	

Telephone number:	     	

Email address:	     	

Preferred language of communication 
for telephone calls: 
(please tick one box only)	Welsh
	
English

	

Preferred language of written communication: 
(including emails and letters) 
(please tick one box only)	Welsh
	
English
	
Both

	

If your application is accepted a fit person's interview will take place as part of the registration process. In which language would you like your interview to be conducted? 
 (please tick one box only)	Welsh
	
English

	

Do you intend to be in full day to day charge of the provision of day care?	Yes		No		

If the answer is no, you are required to appoint a suitable person in charge who must complete section C of this application. If yes, please also complete section A3 below.

A2. Qualifications and experience
Schedule 1, Part 2, Paragraph 17 and Schedule 2, Part 2, Paragraph 22(3)
Details of your professional / technical qualifications that are relevant to the provision of day care for children under the age of 12 years 	

     

	

Please tell us here about any experience you have had that you think will support your application to provide a day care service for children under the age of 12 years 	

     

	
A3. Please provide details below of any business you are carrying on at present or that you have carried on in the past (Only complete this section if you intend to be in day to day charge of the service. If a separate ‘Person in Charge’ (PIC) is appointed they must complete Section C of this application).
Schedule 2, Paragraph 22(4)
Details of business	Dates you carried on this business
(dd/mm/yyyy)	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	
     
	     	

A4. Your work history
Schedule 2, Paragraph 22(5) 
Please provide details of your employment history covering the period between leaving school and now, including the year and month of each change of occupation. Remember to include periods of study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances to enable checks to be made, if necessary.

Please be sure to include any experience you consider to be relevant to the present application including any previous work with children whether paid or not.

If any of your previous duties involved working with children, give the full reasons why your employment or position ended and please explain how this can be confirmed

Employment
(job title)	From
month/year
(mm/yyyy)	To
month/year
(mm/yyyy)	Reason for leaving	Name, address & tel. no. of employer	
     	          	         	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	
     	          	          	     	     

	

A5. Please supply the names and addresses of two individuals from whom we will take up references
You are not required to provide references if you are not intending to be in full day to day charge of the children in the registered setting
Schedule 2, Part 2, Paragraph 22(5)
The people you name must not be related to you. Both of these referees must be able to comment on your competence to look after children under the age of 12 years. Where possible, one of the referees should be your current or most recent employer. (‘Current employer’ means who you are employed by at the time you submit this application). You should give the name of your current or most recent employer as the first.
Reference 1:
Name:	          

Address:	          

Post code:	     	

Occupation:	          	

Telephone number:	     	

In what capacity are you known to them
e.g. employee, friend, colleague and
how long have they known you?	     	
Reference 2:

Name:	          

Address:	     	
Post code:	     	

Occupation:	          

Telephone number:	          	

In what capacity are you known to them
e.g. employee, friend, colleague and how long have they known you?	     	

A6. Medical practitioner report
Schedule 1, Part 2, Paragraph 18 
Important: You are required to provide a report by a registered medical practitioner as to your physical and mental fitness to look after children under the age of 12 years.

This must be submitted as part of your application. 
A template for this reference is attached (Appendix 1)

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of your physical and mental health.
A7. Disclosure and Barring Service (DBS) check
Schedule 1, Part 2, Paragraph 19 and 20 
You are required to present a current DBS certificate (ie.no older than three months since date of issue) to support your application. This must be the original certificate and not a copy.

Where possible you should obtain one via your employer or umbrella body. Where this is not possible you may contact Care Inspectorate Wales on 0300 7900 126 and an advisor will give you details about how to do this. 

Guidance for Applicants is available and this will provide you with step-by-step guidance on completing your form.

Important: From April 1 2018 all applicants will be required to meet the cost of their DBS application.
A8. Additional Personal Information

The following information is requested under the Children and Families (Wales) Measure 2010 and the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010.  A copy can be found on our website www.careinspectorate.wales

Please note: You are disqualified from registration as a provider of day care or from being directly concerned in the management of any provision of day care in Wales if you or any person living or working in your household is disqualified under the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010.

CIW will carry out various checks, including the Disclosure and Barring Service check, local authority social services departments, and its own records.

A person is able to apply for a waiver from disqualification in certain circumstances.

Have you or any person who lives or works in your household ever:
•	Been refused registration in respect of a children’s home or voluntary home?
	
Yes		No		
•	Had your registration in respect of a children’s
home or voluntary home cancelled?

•	Been concerned in the management of, or had any financial interest in a children’s home or voluntary home in respect of which another person has had their registration cancelled?	
Yes		No	

Yes		No	

If you answered ‘Yes’ to any of the above please provide the names of the person involved, details of the relevant registration authority, name and address of the home, nature of the person’s connection with the home, type of action taken against the person and the date of any such action:
          	

Have you or any person who lives or works in your household ever
•	Been refused registration in respect of the provision of nurseries, day care, child minding or other provision of day care?	

Yes		No		
•	Been disqualified from registration in respect of the provision of nurseries, day care, child minding or other provision of day care?	

Yes		No		

•	Had registration cancelled in respect of the provision of nurseries, day care, child minding or other provision of day care?	

Yes		No		

If you answered yes to any of the above please provide the names of the person involved, details of the registration authority, name and address of the provision, nature of the person’s connection with the provision, type of action taken against the person and the date of any such action
     

Have you or anyone who lives or works in your household ever been disqualified from fostering a child privately?	
Yes		No		

If yes, please provide brief details here, including the name of the person and date
         	

Do you know of any other reason why you may be disqualified from registration as a day care provider under the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010?	

Yes	   No  	

If you answered yes please provide details here
     	

Please be aware that a failure to disclose a matter which would disqualify you from registration as a provider of day care may affect your ability to be granted a waiver.
Social services check
Please complete the attached consent form which authorises CIW to contact social services departments for information.  (see Appendix 2)

Section B: Application made by an organisation

(e.g. registered company/local authority/limited liability partnership or unincorporated association) 

B1. Details asked for in this section are required under the Child Minding and Day Care (Wales) Regulations 2010.
Schedule 2, Part 2, Paragraph 23 (1) (2)
Name of organisation:	     	

Address of organisation:	     	
Post code:	     	

Telephone number:	     	

Email address of the organisation:	     	

Fax number of the organisation:	     	
B2. In the case of an applicant organisation which is a company, please provide the following information
Schedule 2, Part 2, Paragraph 23 (3)
Registered office address, post code or principal office of the company:	     	

Registered company number: 	     	

Registered charity number (if applicable):	     	
B3. If the organisation is a subsidiary of a holding company*, please provide the following information
Schedule 2, Part 2, Paragraph 23 (4) (5)
Name and address, post code of the holding company:
	     	

Name and address, post code of the registered or principal office of the holding company:	     	

Name and address, post code of any other
subsidiary of the holding company:	     	
* The words ‘holding company’ and ‘subsidiary’ are to be interpreted in accordance with Section 1159 of the Companies Act 2006
B4. You are required to provide the additional information listed below with your application
Schedule 2, Part 2, Paragraphs 43 to 45
•	Copies of the last two annual reports for your organisation

•	If your organisation is a subsidiary of a holding company* you will need to attach copies of the last two annual reports (if any) of the holding company and of any other subsidiary of the holding company

•	The last annual accounts of the organisation, if any. 

B5.1 Nominated responsible individual
Schedule 1, Part 2, Paragraphs 21 to 25
This section should be completed by the person nominated as the responsible individual.
[A responsible individual is responsible for the supervision of the provision of day care. In relation to a body corporate, the responsible individual must be a director, manager, secretary or other officer of that organisation. In relation to an unincorporated association, the responsible individual must be an officer or member of that organisation’s governing body. The following personal information relates to the nominated responsible individual].
B5.2
Schedule 2, Part 2, Paragraph 24 (2) 
Title:	Mr:       Mrs:       Ms:       Miss:     Other (Please specify):       	

Full name:	     

Any aliases and former names:	          	

Position held in the organisation:	     

Date of birth:
(dd/mm/yyyy)	     	

Address:	     	
Post code:	     	

Telephone number:	     	

Email address:	     	

Preferred language of communication 
for telephone calls: (please tick one box only)	Welsh
	
English

	
Preferred language of written communication: 
(including emails and letters) (please tick one box only)	
Welsh
	
English
	
Both

	
If your application is accepted a fit person's interview will take place as part of the registration process. In which language would you like your interview to be conducted?  (please tick one box only)	Welsh
	
English

	

B5.3 Qualifications and experience
Schedule 1, Part 2, Paragraph 22 / Schedule 2, Part 2, Paragraph 24(3) (a) & (b)
Details of your professional / technical qualifications that are relevant to the provision of day care for children under the age of 12 years: (this only applies when the responsible individual is also the Person in Charge) 
     

     	
Please tell us here about any experience you have had that you think will support this application to provide a day care service for children under the age of 12 years
     	

If there is to be a person in charge please state your qualifications and experience relevant to the supervision of the provision of day care
     	

B5.4 Your employment history
Schedule 2, Part 2, Paragraph 24(4)(a)(b)(c) (this only applies when the responsible individual is also the Person in Charge) 

Please provide details of your employment history covering the period between leaving school and now, including the year and month of each change of occupation. Remember to include periods of study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances, to enable checks to be made if necessary. Please be sure to include any experience you consider to be relevant to the present application including any previous work with children whether paid or not.

If any of your previous duties involved working with children, give the full reasons why your employment or position ended and please explain how this can be confirmed.

Employment
(job title)	From
(mm/yyyy)	To
(mm/yyyy)	Reason for leaving	Name, address & Tel no. of employer	
     
	     	     	     	          	
          	     	     	     	          	
     
	     	     	     	     	
     
	     	          	     	          	
     
	     	     	     	          	
     
	     	     	     	          	
          	     	          	     	     	
          	          	          	          	          	
Please continue on a separate sheet

Please use the space below to explain any gaps in your employment record above (include dates)
     	

B5.5 Please supply the names and addresses of two individuals from whom we will take up references 
Only required if you intend to also be the person in charge
Schedule 2, Part 2, Paragraph 24(4)(d)
The people you name must not be related to you. Both of these referees must be able to comment on your competence to look after children under the age of 12 years. Where possible, one of the referees should be your current or most recent employer. (‘Current employer’ means who you are employed by at the time you submit this application). You should give the name of your current or most recent employer as the first.
Reference 1:
Name:	     

Address:	     	
Post code:	     	

Occupation:	     

Telephone number:	     	

In what capacity are you known to them
e.g. employee, friend, colleague and how 
long have they known you?	     	
Reference 2:
Name:	     

Address:	     	
Post code:	     	

Occupation:	     

Telephone number:	     	

In what capacity are you known to them
e.g. employee, friend, colleague and how
long have they known you?	     	

B5.6 Medical practitioner report
Schedule 1, Part 2, Paragraph 23 and Schedule 2, Part 2, Paragraph 46
Important: You are required to provide a report by a registered medical practitioner as to your physical and mental fitness to look after children under the age of 12 years.  A template for this reference is attached (Appendix 1)

This must be submitted as part of your application.

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of your physical and mental health.
B5.7 Disclosure and Barring Service (DBS) check
Schedule 1, Part 2, Paragraphs 24 and 25
You are required to present a current DBS certificate (ie.no older than three months since date of issue) to support your application. This must be the original certificate and not a copy.

Where possible you should obtain one via your employer or umbrella body. Where this is not possible you may contact Care Inspectorate Wales on 0300 7900 126 and an advisor will give you details about how to do this. 

Important: From April 1 2018 all applicants will be required to meet the cost of their DBS application.

Guidance for Applicants is available and this will provide you with step-by-step guidance on completing your form.

Section C. Information about the person in charge
Schedule 1, Part 2, Paragraphs 26 to 31 and Schedule 2, Part 2, Paragraph 25
This section applies to a person in charge who is not the applicant or the responsible individual.
C1a.
Title:	Mr:      Mrs:      Ms:      Miss:     Other (Please specify):      	

Full name of the person in charge:	     	

Any aliases and former names:
	     	
C1b.
Date of birth:
(dd/mm/yyyy)	     	

Address:	     

	
Post code:	     	

Telephone number:	     	

Email address:	     	

Preferred language of communication 
for telephone calls: 
(please tick one box only)	 Welsh
    	
  English

	

Preferred language of written communication: 
(including emails and letters) 
(please tick one box only)	  Welsh
     	
 English
     	
   Both

	

C2. Qualifications and experience
Schedule 1, Part 2, Paragraph 28 and Schedule 2, Paragraph 25(3)
Details of professional / technical qualifications that are relevant to the provision of day care for children under the age of 12 years.

         

 

	
Please tell us here about any experience the person in charge has had that you think will support this application.

     

C3. Work history
Schedule 2, Part 2, Paragraph 25(4)(a)(b)(c)
Please provide details of the person in charge’s employment history covering the period between leaving school and now, including the year and month of each change of occupation. Remember to include periods of study and volunteering.

Where there are gaps in employment please explain, giving enough detail of the circumstances, to enable checks to be made if necessary.

Please be sure to include any experience you consider to be relevant to the present application including any previous work with children, whether paid or not.

If any previous duties of the person in charge involved working with children give the full reasons why the employment or position ended and please explain how this can be confirmed.

Employment
(job title)	From
(mm/yyyy)
	To
(mm/yyyy)
	Reason why employment ended	Name, address & Tel no. of employer	
       
   	          	          	          	          	
          
	          	          	          	          	
     
     	          	          	          	          	
          	          	          	          	          	
          	          	          	          	          	
          	          	          	          	          	
          	          	          	          	          	
          	          	          	          	          	
Please continue on a separate sheet

Please use the space below to explain any gaps in employment record above (include dates)

     

	
C4. Please supply the names and addresses of two individuals from whom we will take up references
Schedule 2, Paragraph 25(4)(d)
The people you name must not be related to you. Both of these referees must be able to comment on your competence to look after children under the age of 12 years. Where possible, one of the referees should be your current or most recent employer. (‘Current employer’ means who you are employed by at the time you submit this application). You should give the name of your current or most recent employer as the first.
Reference 1:
Name:	     
	
Address:	     	
Post code:	     	
Occupation:	     	
Telephone number:	     	
In what capacity are you known to them
e.g. employee, friend, colleague and how long have they known you?	     	
Reference 2:
Name:	     

Address:	     	
Post code:	     	
Occupation:	     	
Telephone number:	     	
In what capacity are you known to them
e.g. employee, friend, colleague and how long have they known you?	     	
C5. Medical Practitioner report
Schedule 1, Part 2, Paragraph 29, Schedule 2, Part 2, Paragraph 46
Important: You are required to provide a report by a registered medical practitioner as to the physical and mental fitness of the person in charge to look after children under the age of 12 years. A template for this reference is attached. (Appendix 1)

This must be submitted as part of your application.

If you are unable to obtain this report please explain why and provide a statement on a separate sheet as to the state of the physical and mental health of the person in charge.

C6. DBS certificate
Schedule 1, Part 2, Paragraphs 30 and 31
You are required to present your current DBS certificate (ie.no older than three months since date of issue) to support your application. This must be the original certificate and not a copy.

Section D: Information about the care provided including details of the premises
Schedule 2, Part 2, Paragraphs 26 to 32
Please provide the following details in respect of the premises at which children are to be looked after.
Schedule 2, Part 2, Paragraph 26
Name:	     	

Address:	     	
Post code:	     	

Telephone number:	     	

Fax number, if any:	     	

Email address, if any:	     	
Statement of Purpose
Schedule 2, Part 2, Paragraph 27
You are required to submit a Statement of Purpose with this application. The information that you must include in your Statement is prescribed in Regulation 15(1) of the Child Minding and Day Care (Wales) Regulations 2010 as amended by the Child Minding and Day Care (Wales) (Amendment) Regulations 2016.

Please provide details below of the proposed hours you wish to be registered for to provide day care for children. 
Schedule 2, Part 2, Paragraph 28
Monday between	     	and	     	hours	
Tuesday between	     	and	     	hours	
Wednesday between	     	and	     	hours	
Thursday between	     	and	     	hours	
Friday between	     	and	     	hours	
Saturday between	     	and	     	hours	
Sunday between	     	and	     	hours	

Are you the owner of the proposed day care premises?		Yes        No  

If no, are the premises: 			leased?  		rented?  

Who owns the property?  
     

If leased or rented how much notice is required to vacate the premises?	     	

Are the premises purpose built or have they been converted for day care?
     	

Important: Planning permission and building control

You are advised to seek advice on planning permission from your local authority planning department. You must also ensure that the local authority building control department is satisfied with the standard of any building work undertaken. 

For each room you intend to use, please fill in the following details using metres and centimetres where measurements are required:

Storey
e.g. basement/
ground/first  floor etc.	Use of room (e.g. baby, playroom)	Measurement	Type of heating
(Reg 25)	Window	
     	     	     	     

	
Yes	
No		
     	     	     	     
	
Yes	
No		
     	     	     	     	
Yes	
No		
     	     	     	     	
Yes	
No		
     	     	     	     	
Yes	
No		
Kitchen facilities

Storey	Proposed use:
(i.e. food preparation, baby milk, utility room, kitchen)	
     	     	
     	     	
Toilet facilities (including staff/disabled)
Storey	Toilets
(indicate number for children (CH); adult (AD); disabled (DIS)	Wash hand basin

(indicate number)	Nappy change areas

Yes/No	
     	     	     	Yes	
No		
     	     	     	Yes	
No		

How do you intend to manage the disposal of nappies/ clinical waste? (Regulation 25)
          	

How do you propose to provide or manage laundry facilities? (Regulation 25)
     

	
Outside play space(s)
(Regulation25/37) 

Type of surface
     

How are the perimeters of the site secured?
     

Please include a description of the area in which your premises are located including facilities for parents to drop off and collect their children. (Regulation 37)
     

	

You are required to submit an up to date plan of the premises with this application. (Regulation 37)

If no plan is available you will need to draw one and mark the actual dimensions of each room on it in metres and centimetres.  This will assist us in considering your application.  The drawing need not be to scale, but should accurately show the size(s) and positions of windows, internal doors between rooms, stairs and exits to the open air.

CIW needs to be satisfied all parts of the premises to be used by the children are secure from unauthorised access. (Regulation 37)

Please state below the security arrangements at the premises including:

•	for the purposes of safeguarding access to information held there, (Schedule 2, Paragraph 30a) and
•	for the purposes of restricting access from adjacent premises or, when the premises form part of a building, from other parts of the building (Schedule 2, Paragraph 30b)
     

	

Is it intended that any business or activity be carried on in the premises at the same time as children are looked after there?	
Yes		No		

If yes please provide details below: (Schedule 2, Part 2, Paragraph 31)
     

	
Please use this space to add any further information about the facilities which you believe may be relevant to your application
     

	
Details of the children for whom care is to be provided
Please tell us about the number of children for whom care is to be provided and their ages: 
Details asked for in this section are required under the Child Minding and Day Care (Wales) Regulations 2010 Schedule 2, Part 2, Paragraph 32 
Schedule 2, Part 2, Paragraph 32 
Age range	Insert number	
Birth to under 2 years	  	
2 to under 3 years	  	
3 to 7 years	  	
8 years to under 12 years	  	

Do you intend to care for children overnight?	
Yes		No		

Section E: Information about other persons: staff
Schedule 2, Part 2, Paragraphs 33 and 34
Registered persons must ensure that they comply with Regulation 28 of the Child Minding and Day Care (Wales) Regulations 2010 in respect of their appointment of staff, and obtain the information specified in Part 2 of Schedule 2 to these Regulations.

Please provide the required details below for each person (other than the responsible individual and person in charge) who cares for, or who is to care for, the children for whom day care is provided.

Separate sheets may be required.

Full name:	     

Aliases and former names:	     

Date of birth:
(dd/mm/yyyy)	     	

Duties and responsibilities in relation to that person’s work:	
     	

Will this person be resident on the premises?	
Yes		No		

Is this person a relative of yours?	Yes		No		

If yes please state the nature of the relationship:	     	

Will this person be working:	Full time? 	                      Part time? 	

If part time how many hours per week?	     

Date on which the person commenced work or is intended to commence work	     	

Details of this person’s qualifications, experience and skills relevant to the work they are to perform
     

	

The applicant must complete the following statement in relation to each staff member
Schedule 2, Part 2, Paragraph 34(g) - (l) unless otherwise stated

Name of staff member:	     
	
I confirm that I am satisfied with the authenticity of this person’s qualifications:	
Yes		No		
I confirm that I have verified this person’s experience and skills:	Yes		No		
I am satisfied that this person has suitable qualifications for the work they are to perform:	
Yes		No		
I am satisfied that this person has the necessary skills for such work:	Yes		No		
I am satisfied that this person is fit to work and have contact with children under the age of 12 years:	
Yes		No		
I have received a written statement from this person regarding their physical and mental health:	
Yes		No		

I have received a statement from this person that they are physically and mentally fit for the purposes of the work they are to perform:	
Yes		No		

I am satisfied as to this person’s identity:
	
Yes		No		
I have been provided with a copy of this person’s birth certificate:	
Yes		No		

I have a recent photograph of this person:	
Yes		No		
I confirm that an enhanced criminal record certificate has been issued for this person in respect of which less than 3 years have elapsed since it was issued:
Paragraph 42(1)(a)(i)	
Yes		No	
	
I have obtained two references relating to this person and am satisfied to the authenticity of these references	
Yes		No		
I will make the DBS certificate available for inspection by Care Inspectorate Wales:
Paragraph 42(2)(b)	
Yes		No		
I have a full written employment history for this person and a satisfactory explanation for any gaps in their employment record:	
Yes		No		
I have verified why employment or the position ended when this person was previously employed to work with children:	
Yes		No		

If unable to do this verification, please explain why below:
     

Section F: Information about all other persons
Other than a responsible individual, person in charge, or staff member employed by you to care for the children, does anyone else, aged 16 years or over, work, live or otherwise visit the premises, who is likely to have contact with the children you will be looking after? (This includes a person who works on a voluntary basis)	Yes		No  	

If no, go to Part 2 of the application.

If yes, then, in respect of all such persons you will need to supply the following personal details and the person may need to have an enhanced Disclosure and Barring Service criminal record check.

This information is requested under Schedule 2, Part 2, paragraphs 35 to 37

Full name of adult including any alias and former name	Date of birth
(dd/mm/yyyy)	Address (if different from the premises address)	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
          	          	          	
(Please continue on a separate sheet if necessary)

I confirm that an enhanced DBS criminal record certificate has been issued in respect of each of the above named persons.	
Yes		No  	

If no please note that you will be responsible for ensuring any such persons are appropriately supervised at all times when in contact with the children being looked after.

I confirm I will make the above DBS criminal record certificates available for inspection by CIW. 
Paragraph 42(2)(b)	
  Yes  	No   	

I confirm that where I am not entitled to receive any of the above information, I will ensure that any persons aged 16 years or over who work, live or are otherwise present at the premises and likely to have contact with the children will be appropriately supervised at all times when in contact with the children.	

           Yes	    No  	

Part 2

Meeting the regulations and standards

 

Introduction
This section of your application is to be completed by the applicant (in the case of an organisation this will be the person nominated as responsible individual) and is your opportunity to show that you have understood the principles and requirements expressed in the Child Minding and Day Care (Wales) Regulations 2010 as amended by the Child Minding and Day Care (Wales) (Amendment) Regulations 2016; and the National Minimum Standards for Regulated Child Care (NMS) (2016). You must use this part of the application form to describe the arrangements and resources you will use as a day care provider to comply with the regulations and improve your service over time.

There are eight sections to the National Minimum Standards:

•	Information on service
•	Planning for individual needs and preferences
•	Empowering service users and encouraging life style choices
•	Quality of care
•	Staffing
•	Conduct and management of the service
•	Complaints, protection and other significant events
•	The physical environment

You need to consider how you will promote rights, equality and diversity under each of the headings above.

Each section identifies which regulations and NMS you need to meet and what information you must provide to CIW to demonstrate that you are prepared for registration as a day care provider. There is also reference to Annex A in the NMS which you need to take account of if you intend to provide overnight care. Throughout the form where the term ‘parent’ is used it also means the ‘main carer’ of a child.

It is essential in preparing your application that you read the regulations, which the law requires you to meet, and National Minimum Standards. These can be found on our website: www.careinspectorate.wales

Family Information Service 
You may want to contact your local authority Family Information Service before you apply for registration. Your local authority can provide you with information about the training and support they can offer you before you apply and once you are registered with us. The contact details for your local Family Information Service can be found here.

Section One - Information on service
Information and written contract (including Annex A Overnight Care a.11/a.12) (Not mandatory for open access play provision)

Relevant Regulation	

15	
Linked NMS
(Refer  to Annex A if appropriate)	

1 & 2	

Outcomes	
•	Parents have all the information they need to make an informed choice about the child care service they require.

•	Parents have a written contract they have agreed with the registered person.	

•	You must provide a written statement of purpose which describes your day care service and how it will operate, providing information for anyone wishing to use it. The content of your Statement of Purpose is prescribed in Regulation 15 and NMS 1

•	You must also provide a written contract that sets out the expectations of parents regarding the care of the child, activities provided and business arrangements. You should make sure your contract covers all the information in NMS 2. An agreed and signed contract with the parent/carer must be in place for every child.

Please tell us below how you will provide parents with this information (Statement of Purpose and contract) and how often you intend reviewing/updating this information
     	

Please provide a copy of your Statement of Purpose (Regulation 15, NMS 1.2)
Section Two - Planning for individual needs and preferences
Assessment; meeting individual needs and keeping records. Some information is not mandatory for open access play provision - check with the NMS.

Relevant Regulations	
15, 20, 21, 22, 23, 24 26 29,        30, 31, 32, 37 and
Schedule 3	

Linked NMS	

3, 4 & 5	

Outcomes	
•	All children have their needs and preferences identified and their parents know how these will be met

•	Each child’s individual needs, including any communication, cultural, special educational needs and disabilities, are planned for and provided for

•	Parents and CIW have access as appropriate to a full range of records maintained by the registered person for the smooth running of the setting.	

•	The assessment: you must develop a form to use with parents that will make sure you understand each child’s needs, what parents expect from you and confirmation that your service will be able to meet these needs and expectations

•	You must prepare a policy that describes how you will assess, plan for and meet any communication, cultural, special or additional needs children in your care may have and include how you will make sure that staff employed will meet this standard

•	You must ensure that you keep records as required by Regulation 30 and Schedule 3 of the Child Minding and Day Care (Wales) Regulations 2010

Please tell us below:
•	What you would consider with parents to ensure that you will be able to meet each child’s individual needs and preferences
•	How you will ensure that childrens’ home language is given due consideration and children are provided with opportunities to use and experience the Welsh language, traditions and cultural celebrations 
•	How you will ensure that your staff have the necessary skills and experience to plan for and meet each child’s individual needs and preferences
•	How you intend to promote the rights and development of all children by planning for a good variety of play, learning, recreational and leisure opportunities
•	How you will track the progress of children up to eight years and use information and observation to plan for the next steps in their play and learning
•	How you will ensure that children over eight years are able to determine and control the content of their play by following their own ideas and interests 
•	How you will ensure information about each child is kept up-to-date
•	How you will store these confidential records and, where required, make them available

     

	

Please provide a copy of your special needs policy (NMS 4.6)

Section Three - Empowering service users, encouraging life style choices
Working in partnership with parents (including Annex A a.9 & a.10) and opportunities for play and learning

Relevant Regulations	
16, 32, 20, 27 & 37	
Linked NMS	
6 & 7
including Annex A a.9   & a.10  if appropriate	

Outcomes	
•	Parents are kept fully involved in and informed about their child’s activities, achievement and progress

•	Children have a range of experiences - including freely chosen, unstructured and self directed play that contribute to their emotional, physical, social, intellectual, language and creative development.

•		

Parents’ primary responsibility for their children must be recognised and respected. They must be fully informed about the day care setting’s routines and child care practices

Please tell us below how you will:
•	Keep parents informed and involved in the care  of their child
•	Seek feedback from parents about the service you are providing
•	Demonstrate a good understanding of the importance of play and the different types of play for the age ranges of children you care for
•	Listen to children and value their contribution
•	Ensure children can influence the activities and tasks they do
•	Promote a sense of fun and enjoyment
•	Ensure children have access to furniture, equipment, toys and materials that are appropriate and suitable for their needs and which promote cultural awareness and equal opportunities
•	Ensure children have extended periods of child initiated, uninterrupted play as well as frequent opportunities for adults to play alongside them
•	Provide play resources that are easily accessible to children through good storage and labelling (in English and Welsh)
•	Help children to cope with new situations;  freely explore their environment and use their imagination
•	Manage risk and ensure there is a clear understanding of the difference between acceptable and unacceptable risk for the age group of children using the service
•	Ensure that access to toys, electronic games, DVDs and the internet is well monitored to ensure they are appropriate to the children’s age and stage of development
•	Ensure children have the opportunity to show or talk about what they have been doing

Also, describe what specific resources, play opportunities and activities you intend to provide including babies’ activities

     

     	

Please provide a copy of your confidentiality policy

Section Four - Quality of care
Nurture and wellbeing, behaviour, health care, medication and food and drink

Relevant Regulations	
20, 21, 23, 24, 25,
26, 27, 29, 30,
31 & 37	

Linked NMS	
8, 9, 10, 11 & 12   including Annex  a.9 & a.8 if appropriate	

Outcomes	
•	Children feel secure, happy and comfortable with their carers and in their environment, and their rights are respected

•	The behaviour of children is managed in a way that respects their rights and promotes their welfare and development

•	The health care needs of each child are identified and addressed as appropriate and children benefit from the way in which good health is promoted

•	Children are safeguarded by the setting’s policies and procedures about medication, and receive the medication they need

•	Children are provided with regular drinks and food in adequate quantities for their needs.	

You must prepare the following:
•	A written behaviour management policy stating the methods used to manage children’s behaviour: This should include a statement on how you will deal with bullying

•	A written policy describing your procedure and management for storing and administering medication

•	A written procedure that describes what action you will take if a child becomes lost/missing or is not collected

You must:
•	Ensure that at all times there is at least one member of staff with a current first aid at work certificate on the premises

•	Ensure that at least 50 per cent of staff on the premises at any one time are trained in first aid for infants and children under the age of 12 years.

•	Keep a first aid box

•	Keep a record of any medicine administered to a child

•	Prepare a form for parents to give their consent for you to give medicine to their child

If you are providing food for children you need to contact the Food Standards Agency in order to register with them

It is good practice to have training in basic food hygiene - you need to contact your local Family Information Service to arrange this 

We advise that you plan a healthy eating menu for the children in your care, taking account of individual needs and preferences

You must ensure that staff are aware of the United Nations Convention on the Rights of the Child and its implications for their interaction with children

Please tell us in the box below how you would:
•	Promote understanding of child development and how this impacts upon children’s behaviour
•	Encourage all children to co-operate, share, understand accepted rules of behaviour, how to relate to others, contribute to decision making and become self-disciplined
•	Settle children into your day care  setting
•	Manage children’s unacceptable behaviour and tackle any instances of bullying
•	Raise  any concerns with parents about a child’s behaviour and work together to implement ways to manage unwanted behaviour
•	Promote good health of the children you look after and prevent the spread of infection and what you would do  if any child  is ill, or has to be  excluded due to illness
•	Record a child’s health needs and any observations or concerns you may have, and how these will be raised with parents
•	Identify the risks around the administrating of medication and how you would seek advice and training, if required
•	Respond to any medical emergencies
•	Manage meal times, provide a balanced and nutritious diet that takes account of individual needs, preferences and any food allergies
•	Implement best practice in relation to healthy eating/lifestyle programmes to improve outcomes for children

     

 	

Please provide copies of your:
•	Behaviour management policy (Regulation 23, NMS 9.2)
•	Medication  policy (NMS 11.5)
•	Lost/missing/not collected procedure (Regulation 30 and Schedule 3, Paragraph 13)
•	First aid certificates (Regulation 24(2)(b) and NMS 10.14)

Section Five - Staffing
Suitable Person (Reference to NMS Annex B Nursery Schools if applicable)

Relevant Regulations	
6, 9, 27, 28, 29	
Linked NMS	
13 (DC)	

Outcomes	
  Children’s needs are fully met by those who look after them.	

•	The registered person must ensure that all staff employed are suitable to look after children under the age of 12 years. You are asked to provide evidence of this in Part 1 of this application

•	The registered person must ensure staff have adequate training, including induction training in their first week of employment, one to one supervision and an annual appraisal

•	You must prepare a written policy and procedure for staff discipline

Please provide information below about:
•	Your knowledge of child development and how you propose to keep up-to-date with	any changes in this area
•	How you will ensure that your recruitment process means that the most appropriate people are appointed for their roles
•	How you will ensure that your staff team remain suitably qualified and skilled to safeguard and promote the welfare of children
•	Your arrangements for supervision and appraisal of all staff
•	How you would ensure that everyone understands their roles and responsibilities with regard to safeguarding, promoting healthy lifestyles, personal care, personal safety and relationships

          

	

Please provide a written policy and procedure for staff discipline (Regulation 29)

Section Six - Conduct and management of the service
Organisation, staffing ratios (including NMS Annex A if applicable), equal opportunities, financial procedures and quality assurance

Relevant Regulations	
6, 9, 15, 16, 17, 18,
20, 27, 28, 32, 33,	
Linked NMS	
14, 15, 16, 17, 18	

Outcomes	
•	Parents and children benefit from a well organised and planned day care service

•	Children benefit because the ratio of adults to children conforms to best practice

•	All children are treated with equal concern and respect

•	Children and their parents are safeguarded by the registered person operating sound financial procedures

•	Children and their parents benefit from a quality service that is effectively monitored	

You must:
•	Have appropriate public liability insurance (Schedule 2, Part 2, Paragraph 41 and NMS 17.2)

•	Set up and keep a system for monitoring and improving the quality of care given to children (Regulation 16). The quality of care must be reviewed annually and you must obtain the views of children, parents, staff and other significant persons. You will be required to complete a Self Assessment of Service Statement (SASS) form, which is issued by CIW every year (Regulation 17). This will be accepted as your annual review of quality of care providing it meets the requirements of Regulation 16 and is in such a format that can be understood by parents and other significant persons

CIW may make requirements about your service - you must let CIW know that you have completed them by the given date. (Regulation 18)

You should:
•	Prepare a written policy that explains how you promote equality of opportunity and anti-discriminatory practice

•	Develop and periodically review an operational plan (refer to NMS 14.1 for content)

•	Ensure any vehicle used to transport children is roadworthy and has appropriate car insurance which includes business use

•	Keep a record of all financial transactions for your business.

Please tell us below:
•	How you will ensure that the service complies with all relevant regulations and meets the National Minimum Standards

•	How you will continue to demonstrate a sound understanding of current best practice relevant to children in your care and effectively promote this

•	What you understand to be the role and responsibilities of the registered person

•	What you understand to be the role and responsibilities of the person in charge

•	How you intend to promote a strong culture of continuous professional development

•	How you will ensure that staff supervisions and appraisals are meaningful

•	About the activities and resources you will develop and use to help children understand and learn about a wide range of people and cultures in our society

•	How you will monitor the quality of your service and seek the views of children, parents and other interested parties on the quality of care you provide. 
          

	

Please provide copies of the following:
•	your equal opportunities policy (NMS 16.2)

•	your operational plan (NMS 14.1 and 21.11)

Section 7 - Complaints, protection and notifications of significant events
Complaints, safeguarding and child protection and notifying CIW of changes/significant events

Relevant Regulations	
10, 11, 15, 22, 23,
28, 31, 32, 33, 34,
35, 36	

Linked NMS	

19, 20 & 21	

Outcomes	
•	Children and their parents are confident that their complaints will be listened to, taken seriously and acted on

•	Children are protected from harm and abuse and parents are confident that all reasonable steps to protect children from abuse are taken.	

You must:

•	Have a written complaints procedure in line with the regulations which inform parents how you will deal with any concerns they have, and what you will do if they are not satisfied. 
(Regulation 32)

•	Keep a record of all complaints (Regulation 33 (5))

•	Ensure that parents are aware that CIW is the organisation that registers and inspects your service and give parents the contact details for the local CIW office (Regulation 32(6))

•	Provide a written child protection policy that links into the arrangements of the Safeguarding Children Board (LSCB) and identifies how to access the All Wales Child Protection Procedures. The policy must include local contact telephone numbers for reporting concerns you might have about a child in your care (Regulation 22)

Notify CIW of the occurrence of any of the events listed in Schedule 4 of the Child Minding and Day Care (Wales) Regulations 2010 and other requirements for notification.  A notification form, which lists all notification requirements, is available on our website https://careinspectorate.wales/day-care-and-play-notification-form

Please tell us below:

•	How you would ensure that children understand how to raise concerns/complaints and are supported to do so in a safe environment
•	How you would deal with a concern or complaint from a parent
•	How you would ensure that lessons are learnt and appropriate action is taken in relation to any concerns or complaints made about the service
•	How you would deal with a potential child protection issue, including allegations made against yourself or a member of staff
•	What systems you will have in place to ensure all significant events and changes to your service are promptly notified to CIW.

     

	

Please provide copies of your:
•	complaints  procedure (Regulation 32 and NMS 19.1)
•	child protection policy (Regulation 22 and NMS 20.2)

Section Eight - The physical environment
Environment, equipment and safety

Relevant Regulations	
20, 25, 37*, 38	
Linked NMS	
21, 22 & 23	

Outcomes	
•	Children are cared for in an environment that is safe, secure and suitable for their purpose

•	There is sufficient space to meet the needs of all children using the service

•	Children have access to furniture, equipment, toys and materials that are appropriate and suitable for their needs

•	Children are cared for and have their needs met in a safe environment that includes indoor and outdoor play areas 

*Please note: Regulation 37 (2) does not apply to a registered person who provides day care by means of open access play provision.

You must:
•	Provide adequate space and access to all the necessary facilities for a range of activities which promote children’s development

•	Keep hazards for children to a minimum and ensure health and safety regulations are complied with

•	Ensure risk assessments in relation to the health and safety of the children are undertaken, reviewed and available to parents and CIW

•	Have an emergency evacuation procedure for the setting

Please describe below how:
•	How you will ensure that the layout and design of the environment promotes childrens’ independence and is considered from a child’s perspective
•	How you will ensure the premises and any outside play areas are secure, welcoming, friendly and provide a rich environment for play and learning
•	You will ensure that the premises are safe, secure, well maintained and suitable for its purpose
•	You will make the premises welcome to children
•	You will ensure that furniture, equipment and toys are well maintained and conform to BS EN safety standards or relevant Toys (Safety) Regulations
•	How you will ensure that cleaning routines reflect good hygiene practices and effective infection control
•	How you will ensure that everyone is aware of their responsibilities in relation to the safety and welfare of children; that everyone understand health and safety requirements applicable to the service and follow the service’s related policies and procedures
•	You will ensure children are adequately supervised at all times (this includes trips away from the premises)

      

   	

Please provide copies of your:

•	Risk assessments

•	Up-to-date safety certificates for gas/electrical/oil burning appliances (NMS 23.18)

•	Statement of the procedure to be followed in the event of a fire or accident 
(Regulation 30 and Schedule 3, Paragraph 10 and NMS 5.1).

Checklist of documents to be supplied with this application

Is the applicant also the person in charge?   			Yes  	No  
Schedule 2, Part 2, Paragraphs 38 - 46
In relation to an application made by an individual (in cases of more than one individual applicant the following documentation must be supplied in relation to each of them):
	
Person to be registered and in day to day charge of the children                   Tick here

Birth certificate:	

Proof of identity: 		

A recent photograph:		

A valid DBS certificate (this must be the original certificate and no more than three months old since the date of issue).	

Certificates or other suitable evidence relating to professional or technical qualifications relevant to looking after children under the age of 12 years:	

A report by a registered medical practitioner as to physical and mental fitness to look after children under the age of 12 years or, if this is unobtainable, a statement by the applicant as to the state of their physical and mental health:	

Signed and dated Social Services Department enquiry consent form for the person to be registered and anyone over the age of 16 years who is living on the premises to be registered:	
	
In relation to an application made by an organisation                                      Tick here
Birth certificate for the nominated ‘responsible individual’:		

Proof of identity: 		

A recent photograph of the nominated ‘responsible individual’:		

A valid DBS certificate (this must be the original certificate and no more than three months old since the date of issue).	

A report by a registered medical practitioner as to whether the responsible individual is physically and mentally fit to look after children under the age of 12 years or, if this is unobtainable, a statement from the responsible individual as to the state of their physical and mental health:	

        	

Certificates or other suitable evidence relating to the relevant professional or technical qualifications of the responsible individual:	

Copies of the organisation’s last two annual reports:	 	

If the organisation is a subsidiary of a holding company the last two annual reports  (if any) of the holding company and any other subsidiary of that holding company:	

The last annual accounts of the organisation, if any:	  	
In respect of the person in charge:                                                                        Tick here
Birth certificate:	         	

Proof of identity: 	         	

A recent photograph:

Certificates or other suitable evidence relating to the professional or technical qualifications relevant to looking after children under the age of 12 years:	

A report by a registered medical practitioner as to whether the person in charge is physically and mentally fit to look after children under to the age of 12 years or, if this is unobtainable, a statement from the person in charge as to the state of their physical and mental health:	

	
Documentation required in respect of the premises:
Plan of premises:		

Certificate of Insurance in respect of liability which may be incurred in respect  of death,  injury, public liability, damage or other loss occurring in relation to the proposed provision of day care:	

Other documentation as requested in Part 2: 
Statement of Purpose (Regulation 15 and NMS 1.2)                                                       
Your special needs policy (NMS 4.6)                                                                               
Your confidentiality policy                                                                                                 
Behaviour management policy (Regulation 23 and NMS 9.2)                                          
Medication policy (NMS 11.5)                                                                                           
Lost/missing/not collected procedure (Regulation 30 and Schedule 3, Paragraph 13)    
First aid certificates (Regulation 24(2)(b) and NMS 10.14)                                               
Staff disciplinary procedure                                                                                               
Your equal opportunities policy (NMS 16.2)                                                                      
Your operational plan (NMS 14.1 and 21.11)                                                                    
Complaints procedure (Regulation 32 and NMS 19.1)                                                      
Child protection policy (Regulation 22 and (NMS 20.2)                                                     
Risk assessment of the premises                                                                                      
Annual safety check for gas/electrical/oil burning appliances (NMS 23.18)                      
A statement of the procedure to be followed in the event of a fire or accident 
(Regulation 30 and Schedule 3, Paragraph 10 and NMS 5.1)                                          
Please note:
If the required documents are not submitted with the application, CIW will not accept 
the application.

Wherever possible, the applicant should bring their completed application form and all supporting documentation to the local CIW office in person

Please remember to bring your completed Disclosure and Barring Service application forms.  
We will also require a recent passport size, or larger, photograph which is a current true 
likeness. This will be retained as part of your application.

You are advised to make a prior appointment for the purpose of lodging your application.

Important: All childcare providers must comply with other relevant legislation including that which covers for example, health and safety; disability discrimination; food hygiene; fire and planning. 

Failure to comply with other relevant legislation may be considered by CIW in relation 
to your fitness as a registered person.

Section G: Declaration
The information I/we have provided in this application form and in any attached documents is, to the best of my knowledge and belief, true and accurate.  I/we understand that it is an offence to knowingly make a statement in an application for registration which is false or misleading in a material particular and to do so may lead to my/our prosecution and/or the refusal or subsequent cancellation of my registration.

In making this application for registration under the provisions of the Children and Families (Wales) Measure 2010 I/we agree to comply with the Child Minding and Day Care (Wales) Regulations 2010 taking into account the National Minimum Standards for Regulated Child Care.

I/we agree to Care Inspectorate Wales undertaking whatever checks it deems necessary to verify my suitability:

This application must be signed by all individual applicants.

An application made by an organisation must be signed by the responsible individual.

Important: 
We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.

Signed:	     	Date:	     	
Signed:	     	Date:	     	
Signed:	     	Date:	     	
When you have completed this form please contact CIW to make an appointment to submit your application.

You are advised to keep a copy of this form for ongoing reference and guidance.

Appendix 1 Medical reference 

Medical reference for Care and Social Services Inspectorate (Wales) in respect of a person applying to be a Child Minder or Day Care provider
This section to be completed by the applicant:
Name: 	          

Address:

Postcode:	     	

Telephone number:	     	

Email:	          	

Date of birth:
(dd/mm/yyyy)	     	

Place of birth:	     	

Maiden name:	     	

Any other surnames:

	     	

This section to be completed by the applicant’s GP:
Name:	     

Address:	     	
Post code:	     	

Telephone number:	     
	
Note to GP
Before completing the declaration below, please consider any existing medical condition for which the applicant is being treated at the moment and any hospital admissions over the last five years which may be relevant.

It is my opinion that after reading the medical notes of:	          	

The applicant is physically and mentally fit to look after children under the age of 12 years:	

OR

The applicant has a condition or disability (including mental disability) which may affect his/her ability to look after children under the age of 12 years:	

GP
Signature:
	     	Date:	     	

Surgery Stamp:

Appendix 2 Social Services consent form

Declaration and consent for CIW to contact Social Services Departments
Children and Families (Wales) Measure 2010 and the Child Minding and Day Care (Disqualification) (Wales) Regulations 2010

A separate form must be completed by the applicant and all persons over 16 years who live at the premises to be registered. This form is also available as a separate document on the Care Inspectorate Wales website (https://careinspectorate.wales).

Full name and address:	     

	

Post code:	     	

Date of birth:
(dd/mm/yyyy)	     	
Previous full addresses in the last five years:
Address 1:	Address 2:	
     		     	
Post code:	Post code:	
     		     	

From:	     	Until:	     	       From:	     	  Until:	     	

Address 3:	Address 4:	
     		     	
Post code:	Post code:	
     		     	

From:	     	Until:	     	  From:	     	  Until:	     	

Address 5:	
     	
Post code:	
     	

From:	     	   Until:	     	

Have you ever been the subject of a care or supervision order?	
Yes 		No		

Have you had a care or supervision order made with respect to a child in your care?	
Yes 		No		

Have you ever been disqualified from fostering a child privately?	
Yes 		No		

If yes to any of the above, please provide details including dates and the Local Authority involved:
     	

Please give the following details of children who currently live with you and of those who may now live elsewhere:
Full name of child:	Date of birth:
(dd/mm/yyyy)	Relationship to you:	
     	          	     	
     	          	     	
     	          	     	
     	          	     	
     	          	     	
     	          	     	

Have you ever been disqualified from fostering children?	Yes 		No		

If yes, please give details including date of disqualification, reasons for disqualification and the local authority involved.
     	

I confirm that the information provided above is correct and I give my consent to Care Inspectorate Wales contacting my local or any relevant Social Services Department to be satisfied I am not disqualified from registration to provide day care for children under the age of 12 years.

Name:	          

Signature:	     	

Date:
	     	

 Please return this to your CIW office with your application forms.
Appendix 3 Questionnaire to assess the suitability of the registered person 
Questionnaire to assess the suitability of the registered person
The Children and Families (Wales) Measure 2010
A person must not act as a child minder or provide day care unless the person is suitable to look after children under the age of 12 years. (Regulation 6(1) of the Child Minding and Day Care Regulations (Wales) 2010)

Care Inspectorate Wales (CIW) must be confident that a person applying for registration understands their role and responsibilities as a registered person for a day care service. Where the applicant is an organisation this questionnaire should be completed by the nominated responsible individual.

Please complete this questionnaire and submit with parts 1 and 2 of your application form.

Your application will be considered as a whole, and if necessary you may be called for an interview to discuss any issues arising.

To help you complete this questionnaire you should refer to the following regulations:

•	The Child Minding and Day Care (Wales) Regulations 2010

•	The Child Minding and Day Care (Disqualification) (Wales) Regulations 2010

•	The Child Minding and Day Care (Wales) (Amendment) Regulations 2016

•	The Child Minding and Day Care (Exceptions) (Wales) Order 2010

•	The Child Minding and Day Care Exceptions (Wales) Order 2016

You will also need to be familiar with the National Minimum Standards for Regulated Child Care. 

You can find these Regulations on our website: www.careinspectorate.wales

You may also want to contact your support organisation (Clybiau Plant Cymru Kids Clubs; National Day Nurseries Association; Mudiad Ysgolion Meithrin; Wales Pre-school Playgroups Association; Play Wales).

Name of applicant:	          

Address:	     	
Post code:	     	

Telephone number:	     	

Email address:	          	

Name of service:	          	

Name of person in charge in the service:	     	

1.	What experience and skills do you have which will help you in your role as a registered person? (This may include any personal or professional experience, and does not have to be related solely to child care.)
     

	

2.	What do you understand your role and responsibilities to be as a registered person?
     

	

3.	What is your understanding of the role and responsibilities of the person in charge in your day care setting?
     

	

4.	Tell us how the person in charge will be supported to enable them to receive opportunities for: 
•	Training and professional development
     

	
•	Appraisal
     	
•	Day to day management support
     

	

5.	Which records must you keep about:
•	Children (refer to the Child Minding and Day Care (Wales) Regulations 2010; Regulation 30 and Schedule 3)
        

  	
•	Health and Safety (refer to the Child Minding and Day Care (Wales) Regulations 2010, Regulation 25)
     

	
•	Any staff you employ and volunteers (refer to the Child Minding and Day Care (Wales) Regulations 2010, as amended by the Child Minding and Day Care (Wales) (Amendment) Regulation 2016, Regulation 28 and Schedule 1 and 2)
     

	

6.	Tell us what changes and events you need to inform CIW about  (refer to the Child Minding and Day Care (Wales) Regulations 2010, Regulations 10, 15, 23 and 31 and Schedule 4)

     	

7.	How will you ensure that the provision operates smoothly and meets its objectives with reference to the statement of purpose, staffing, policies and procedures?
     	

8.	How will you establish, monitor and maintain the quality of your service? (refer to the Child Minding and Day Care (Wales) Regulations 2010, regulation 16)
          

	

9.	How do you intend to keep your knowledge and understanding of day care up-to-date?
          

	

Thank you for completing this questionnaire. It will help us to assess your application.  When your application has been considered, you will be contacted by an inspector who will let you know if there is anything more you must do.
Please read and sign the following declaration:
If my application to be a registered person is successful, I understand that I am legally responsible for the continued registration of the setting until I have informed CIW in writing and notified any other registered person of the date I shall cease to be the registered person.

I understand that if there are no registered persons, the setting cannot remain registered by CIW.

Signature of proposed registered person:	     	

Date: