Application Submission Form

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Child Name*

First Middle Last

Preferred Name

Date of Birth*

Month

Day

Year

Gender*

Race (check all that apply)*

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Pacific Islander

White

Other Race

I do not wish to identify my child's race

Please Specify Other Race

Ethnicity*

The best way to describe the amount of English my child speaks or understands is:

The Language(s) my child speaks is (are):

The primary language our family speaks at home*

Please specify other language

Preferred language for Interpreter

Preferred Interpreter

Does your child have any Food or Dietary Restrictions?*

Please specify other food or dietary restriction:

Does your family need full-day and/or full-year care for this child (because you are working or in job training?

If full-day and/or full-year care is not available, are you able to accept a part-time program for your child?

Child Care Assistance: My child is currently

Does your child currently receive care?

Which type of care does your child receive?

Please specify the name of this program:

Did this child participate in CVHS’s Early Head Start Program?

Have any of this child’s siblings ever participated in the CVHS Head Start or Early Head Start?

Please provide the sibling’s name:

Custody Status of this child:*

Parent's Name with sole legal custody

DCF Caseworker:

Please specify other:

Are there any court orders regarding the custody of this child, including DCF or other guardianship orders/documents?

Please upload a copy of the custody documents here:

(A clear/focused cell phone photo may be uploaded. If you are unable to upload documents at this time a CVHS representative will follow up with you. Applications will not be finalized until all required documentation is received.)

Max. file size: 50 MB.

Primary Parent/Guardian*

First name Last name

Date of Birth*

Month

Day

Year

Gender*

Cell Phone*

Home Phone

Work Phone

Email*

Enter Email Confirm Email

Relationship to child:*

Please specify other relationship:

Please specify other transportation:

Do you have reliable transportation?*

Living Address*

(Refers to Primary Parent/Guardian)

Street Address Address Line 2 City State ZIP Code

Is your Mailing Address the same as your Living Address?

Mailing Address

(Refers to Primary Parent/Guardian)

Street Address Address Line 2 City State ZIP Code

Directions to Home (Champlain Valley Head Start provides the opportunity for home-school connections by offering at least 2 home visits per year)

(Refers to Primary Parent/Guardian)

Please answer the following questions. If you answer YES to any of the questions, your family may be automatically eligible to receive Head Start services. If all responses are No then you will be asked to provide a most recent Federal tax return, W-2s, or Paystubs.

Is this child currently in foster care (in the custody of the State of Vermont)?*

Is your family currently experiencing homelessness (Staying in a shelter, hotel, car, campground, transitional housing unit, or sharing the housing of others due to loss of housing or economic hardship)?*

Is your family currently receiving Reach Up?*

Is your family currently receiving 3SquaresVT/SNAP benefits?*

Please upload 3SquaresVT/SNAP Documentation:

Max. file size: 50 MB.

Indicate each type of Family Income received within the last 12 months. You will need to supply documentation.

(Includes all Adults in the Household)

NONE

Child Support

Reach Up (Not currently receiving)

Rental Income

Other

Please specify Other Income:

Please upload a copy of the supporting documentation for any income specified above:

Drop files here or

Max. file size: 50 MB.

Employment Status

(Primary Parent/Guardian)

Have you earned any Income in the last 12 months?*

Type of Income: Income Source 1

How often are you paid? Income Source 1

Gross Amount per pay period: Income Source 1

Please upload supporting documentation: Income Source 1

Max. file size: 50 MB.

Do you have other income or wages from another source in the last 12 months?*

Type of Income: Income Source 2*

How often are you paid? Income Source 2

Gross Amount per pay period: Income Source 2

Please upload supporting documentation: Income Source 2

Max. file size: 50 MB.

Do you have any other income or wages from another source in the last 12 months?*

Type of Income: Income Source 3

How often are you paid? Income Source 3

Gross Amount per pay period: Income Source 3

Please upload supporting documentation: Income Source 3

Max. file size: 50 MB.

U.S. Military Status

(Primary Parent/Guardian)

How often are you paid Veterans Benefits?

Gross Amount of Veterans Benefit in the last 12 months

(Before Taxes)

Please upload a copy of Veterans Benefit

Max. file size: 50 MB.

Job Training/School Status

(Primary Parent/Guardian)

Please provide the job training program:

Please provide the name of the school or program:

Have you received a grant or scholarship for your school within the last 12 months?*

(Primary Parent/Guardian)

Gross Amount of Scholarship/Educational Grant

(Before Taxes)

Frequency of Scholarship/Educational Grant Payment

Please upload a copy of Scholarship/Educational Grant

Max. file size: 50 MB.

Please Select your Education Level:*

Is English your primary language?*

(Primary Parent/Guardian)

Would you need an interpreter?*

The Language(s) that I speak is/are:*

(check all that apply)

Atari

Albanian

Arabic

American Sign Language

Bass (Liberian)

Bengali

Bosnian

Chinese (Mandarin)

Chinese (Cantonese)

Croatian

Dinka

English

Ewe

Farsi

French

German

Hindi

Italian

Japanese

Karen (Burmese dialect)

Kirundi

Kizigna

Kuku

Lingala

Luganda

Maay Maay

Mongolian

Nepali

Polish

Portuguese

Russian

Somali

Spanish

Swahili

Tagalog

Tibetan

Tigrigna

Turkish

Tiwi

Urdu

Vietnamese

Other

Please specify other language

Is there a Secondary Parent/Guardian?*

(Step-Parents should not be listed here. There will be another opportunity to enter their information)

Secondary Parent/Guardian*

First name Last name

Date of Birth*

Month

Day

Year

Gender*

Cell Phone

Work Phone

Enter Email Confirm Email

Relationship to child:*

Please specify other relationship:

Does the Secondary Parent/Guardian live with the family?*

Secondary Parent/Guardian Living Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Directions to Secondary Parent/Guardian Home:

Employment Status

(Secondary Parent/Guardian)

Has the Secondary Parent/Guardian earned any Income in the last 12 months?*

Type of Income: Income Source 1

How often is the Secondary Parent/Guardian paid? Income Source 1

Gross Amount per pay period: Income Source 1

(Secondary Parent/Guardian)

Please upload supporting Secondary Parent/Guardian documentation: Income Source 1

Max. file size: 50 MB.

Do you have other income or wages from another source in the last 12 months?

(Secondary Parent/Guardian)

Type of Income: Income Source 2*

How often is the Secondary Parent/Guardian paid? Income Source 2

Gross Amount per pay period: Income Source 2

(Secondary Parent/Guardian)

Please upload supporting Secondary Parent/Guardian documentation: Income Source 2

Max. file size: 50 MB.

Do you have any other income or wages from another source in the last 12 months?

(Secondary Parent/Guardian)

Type of Income: Income Source 3*

How often is the Secondary Parent/Guardian paid? Income Source 3

Gross Amount per pay period: Income Source 3

(Secondary Parent/Guardian)

Please upload supporting Secondary Parent/Guardian documentation: Income Source 3

Max. file size: 50 MB.

U.S. Military Status

(Secondary Parent/Guardian)

How often are you paid Veterans Benefits?

(Secondary Parent/Guardian)

Gross Amount of Veterans Benefit in the last 12 months

(Before Taxes)

Please upload a copy of Veterans Benefit

Max. file size: 50 MB.

Job Training/School Status

(Secondary Parent/Guardian)

Please provide the job training program:

Please provide the name of the school or program:

Have you received a grant or scholarship for your school within the last 12 months?*

Gross Amount of Scholarship/Educational Grant

(Before Taxes)

Frequency of Scholarship/Educational Grant Payment

Please upload a copy of Scholarship/Educational Grant

Max. file size: 50 MB.

Please Select your Education Level:*

Is English your primary language?*

(Refers to Secondary Parent/Guardian)

Secondary Parent/Guardian need an interpreter?*

The Language(s) that I speak is/are:*

(check all that apply)

Atari

Albanian

Arabic

American Sign Language

Bass (Liberian)

Bengali

Bosnian

Chinese (Mandarin)

Chinese (Cantonese)

Croatian

Dinka

English

Ewe

Farsi

French

German

Hindi

Italian

Japanese

Karen (Burmese dialect)

Kirundi

Kizigna

Kuku

Lingala

Luganda

Maay Maay

Mongolian

Nepali

Polish

Portuguese

Russian

Somali

Spanish

Swahili

Tagalog

Tibetan

Tigrigna

Turkish

Tiwi

Urdu

Vietnamese

Other

Please specify other language

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Does the Step-Parent have any income or wages from another source in the last 12 months?*

Type of Income: Income Source 1

How often is the Step Parent paid? Income Source 1

Gross Amount per pay period: Income Source 1

Please upload supporting Step-Parent documentation: Income Source 1

Max. file size: 50 MB.

Does the Step-Parent have any other income or wages from another source in the last 12 months?*

Type of Income: Income Source 2

How often is the Step Parent paid? Income Source 2

Gross Amount per pay period: Income Source 2

Please upload supporting Step-Parent documentation: Income Source 2

Max. file size: 50 MB.

Does the Step-Parent have any other income or wages from another source in the last 12 months?*

Type of Income: Income Source 3

How often is the Step-Parent paid? Income Source 3

Gross Amount per pay period: Income Source 3

Please upload supporting Step-Parent documentation: Income Source 3

Max. file size: 50 MB.

U.S. Military Status

(Step-Parent)

How often is the Step-Parent paid Veterans Benefits?

(Step-Parent)

Gross Amount of Veterans Benefit in the last 12 months

(Before Taxes)

Please upload a copy of Veterans Benefit

Max. file size: 50 MB.

Job Training/School Status

(Step-Parent)

Please provide the job training program:

Please provide the name of the school or program:

Have the Step-Parent received a grant or scholarship for your school within the last 12 months?*

Gross Amount of Scholarship/Educational Grant

(Before Taxes)

Frequency of Scholarship/Educational Grant Payment

Please upload a copy of Scholarship/Educational Grant

Max. file size: 50 MB.

Please Select Step-Parent Education Level:*

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Does anyone else live in your home? (Please include ALL other family members or any other people.)*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to child*

Does this person currently receive Supplemental Security Income (SSI)?*

Please use this space to tell us about any current circumstances affecting your family that may impact your need for immediate school and/or child care for your child.

Which programming option are you interested in for your child?

Do you have any specific programming requests?

Where did you hear about Champlain Valley Head Start (CVHS)?

Please Specify Other:

Did Anyone Help You Fill Out this Application?

Person who helped fill out application

First Last

Organization of person who helped fill out application

Phone Number of Person who helped fill out application

Email of person who helped fill out application

Authorized Representative

If you would like to give permission to someone to speak with us on your behalf, please fill out this section. By filling out the Authorized Representative section you agree to the following: I understand that I am not required to have an Authorized Representative but I give CVHS and the Authorized Representative permission to communicate with each other and share information about my family and myself for the purposes of applying for the Head Start program and coordinating services for my family. I may revoke this authorization at any time by calling (802) 651-4180 x204 and informing the Enrollment Manager that I am revoking this authorization.

Name of Authorized Representative

First Last

Representative's Phone Number

Authorized Representative's Relationship to you

Authorized Representative's Organization Name (If Applicable)

Release of Information

Head Start & Early Head Start are national programs. Federal regulations require that we obtain certain information in order to determine eligibility for the program and to provide services. In order to best serve your child and family, we sometimes need to share information, in verbal, written, or electronic format, with other agencies. Except as allowed in this authorization and release, Champlain Valley Head Start will not communicate or disseminate any confidential child or family information to organizations or entities outside the organization.

Release for Child (Legal Name)*

First Middle Last

The local school district and/or CIS agency responsible for comprehensive evaluation and development of an IFSP or IEP (if needed) for the purpose of: Obtaining documentation of my child’s comprehensive evaluation and/or IFSP or IEP in order to provide individualized education services to my child and coordinating educational services for my child.*

The local District Office of the Economic Services Division that administers TANF (Reach Up) and SNAP (3SquaresVT) benefits for the purpose of: Obtaining TANF and/or SNAP documentation to determine eligibility for the Head Start program, coordinating the family goal setting process and contacting my family if direct communication methods fail.*

The local school district in which the participant resides for the purpose of: Completing Act 166 / Pre-K registration, including providing documentation for the purposes of proving residency and date of birth of the child and determining the status of the child’s Act 166 / Pre-K registration*

The local Community Care Support Agency that administers the Child Care Financial Assistance program for the purpose of: Obtaining Child Care Financial Assistance documentation to determine eligibility for specific Head Start program options and coordinating the enrollment of my child in Head Start and/or its collaborative partner sites.

The local District Office of the Family Services Division for the purpose of: Obtaining documentation to determine eligibility for the Head Start program and coordinating family safety/support services.

Other Organization

Please Specify Other

Parent/Legal Guardian Name (Printed)*

First Last

Release Date*

Month

Day

Year

By signing this release, I authorize Champlain Valley Head Start to exchange information with, release information to, and/or obtain information from, the organizations listed above. .*

Release of Health and Screening Information

Head Start & Early Head Start are national programs. Federal regulations require that these programs obtain documentation to facilitate up to date health requirements for children and pregnant women and any follow up care needed. Except as allowed in this authorization and release, Champlain Valley Head Start (CHVS) will not communicate or disseminate any confidential child or family information to organizations or entities outside of CVHS and our collaborative partner child care and school sites.

Champlain Valley Head Start Authorization*

By checking this box, I, the parent/guardian indicate my consent to the following:

Obtain the following information from health care providers and state registries for the below named child/pregnant woman:
• medical and dental records (including follow-up care with specialists)
• lead and hemoglobin test results
• immunization records
• developmental screening results
• prenatal and postpartum documentation for pregnant women enrolled in EHS

The above information may be either electronic, written or verbal and will be released to:
Champlain Valley Head Start
Health Coordinator, Special Needs Coordinator,
Nurse Consultant or Tooth Tutor
255 South Champlain St., Suite 10
Burlington, VT 05401
(802) 651-4180 X215

I also consent to:
• Share and discuss results of my child’s Head Start screenings (vision, hearing, growth, oral health, and developmental) and health records with my child’s health care providers and/or state registries or CVHS collaborative partners in order to provide/support services for my child/family.
• Share my child’s growth assessment, enrollment and oral health status with WIC and its Public Health Dental Hygienists.
• If my child is transitioning to public school: share my child’s oral health status with the public school Tooth Tutor.

I acknowledge that:
• I may revoke this consent at any time (by contacting CVHS at the address or telephone number above) except to the extent that action has been taken in reliance on it before I revoked it.
• This consent will expire on December 31, 2025.

Child's Legal Name*

First Middle Last

Child's Date of Birth

Month

Day

Year

Parent/Legal Guardian Name*

First Last

I am the:*

Signature Date (Today's Date)*

Month

Day

Year

By signing this release, I authorize Champlain Valley Head Start to obtain health information as described above:

This application signifies the family’s desire to enroll this child in the Early Head Start or Head Start program. Following completion of this application, the application will be processed and Champlain Valley Head Start will notify the family as to whether the child has been enrolled in the program, and the starting date for services.

Child Name*

First Last

Primary Parent/Guardian Name*

First Last

Consent for Services*

By checking this box, I, the parent/guardian indicate my consent to the following:

• I agree to comply with the rules and regulations of the program.

• I certify that the information I have provided on and in support of this application is accurate and truthful to the best of my knowledge.

• I understand that intentionally providing false, inaccurate, or incomplete information may result in a loss of my family’s eligibility to participate in the program.

• I consent to have my child participate in all health and developmental screenings or non-invasive exams (including, but not limited to: hearing and vision screenings, heights and weights, visual oral health screening) conducted by Champlain Valley Head Start staff, consultants, collaborative partners or others working in conjunction with Champlain Valley Head Start, to help assure compliance with all federal and state regulations. These may take place outside of the classroom. All screening and exam results and recommendations will be shared with me by the program.

• I consent to have my child receive his/her special education and/or mental health services, as outlined in his/her IEP, IFSP/One Plan, and/or treatment plan, during Head Start classroom time. I understand that these services may be provided by special educators, including speech/language pathologists, occupational therapists, physical therapists, and individual assistants, or early childhood mental health professionals and may take place outside of the classroom.

• I understand that the Head Start program utilizes the services of early childhood mental health consultants in order to better provide quality education services by increasing the social and emotional well-being of children. I consent to have my child participate in the services provided by the early childhood mental health consultants. The program will notify me in advance of any services provided individually to my child.

• I understand that Champlain Valley Head Start sometimes records video and/or takes photographs of programs in operation and the participants present for the following purposes: (1) to support the professional development of teachers and staff; (2) to assist the Behavioral Support Specialist in supporting teaching teams who are working with children with challenging behaviors; and 3) as documentation for child outcomes observation and assessment. Additional permissions may be requested for individual children. All videos will be deleted at the conclusion of the process. Video recordings will not be shared outside of CVHS and its collaborative teaching and child care partners. I consent to have my child participate in a classroom where video recording may occur for the purposes outlined above.

I give my permission to Champlain Valley Head Start or its funders/partners to use photos and/or video of my child and/or family with the understanding that my child/family will not be identified by name. Photos or video may be used in newsletters, websites, social media, brochures or other recruitment, outreach, fundraising or promotional materials/reports.*

Signature

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