CVHS Release of Information

Home / CVHS Release of Information

"*" indicates required fields

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 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*

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. .*

CAPTCHA