Champlain Valley Head Start (HSR) Release of Health and Screening InformationHead 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, 2024.Child's Legal Name* First Middle Last Child's Date of Birth* Month Day Year Parent/Legal Guardian Name* First Last I am the:*ParentLegal GuardianDCF Authorized Representative of the above-named childPregnant WomanSignature Date (Today's Date)* Month Day Year By signing this release, I authorize Champlain Valley Head Start to obtain health information as described above: Δ