CVHS Health & Screening Release

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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.

Child's Legal Name*

First Middle Last

Child's Date of Birth*

Parent/Legal Guardian Name*

First Last

I am the:*

Signature Date (Today's Date)*

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

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