CVHS Consent for Services

• I intend to enroll my child in Early Head Start or Head Start if my child is accepted into the program.

• 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 of its classrooms 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. 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.