Expectant Mother Submission Form

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Applicant Name

First Middle Initial Last

Date of Birth

Month

Day

Year

Living Address

Street Address Address Line 2 City State ZIP Code

Is your Mailing Address the same as your Living Address?

Mailing Address

Address Line 1 Address Line 2 City State ZIP Code

Cell Phone

Home Phone

Work Phone

Enter Email Confirm Email

Expected Delivery Date*

MM slash DD slash YYYY

Do you have children who have ever participated in CVHS Head Start or Early Head Start?

Please provide the child’s name:

Is English your primary language?

Would you need an interpreter?

Preferred Language of Interpreter

Preferred Interpreter

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

(check all that apply)

Arabic

Bhutanese

Bosnian

Burmese

Chinese (Mandarin)

Chinese (Cantonese)

Dari

English

French

Karen (Burmese dialect)

Kirundi

Lingala

Maay Maay

Nepali

Pashto

Portuguese

Somali

Spanish

Swahili

Tagalog

Tigrigna

Vietnamese

Other

Please specify other language

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 race

Please Specify Other Race

Ethnicity

Please note, this cultural information will not impact your enrollment in the program. This information will not be shared outside of Champlain Valley Office of Economic Opportunity (CVOEO), of which CVHS is a program.

Were you born in the U.S.?*

(Applicant)

Are you a current or former refugee?*

(Applicant)

The primary language our family speaks at home

Can your family go the SAME PLACE, EVERY NIGHT to sleep in a SAFE & SUFFICIENT SPACE?

Does your family have stable long-term housing? (check no if you are currently staying in a shelter/ transitional housing)

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 applicant 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.

Is your family CURRENTLY receiving Supplemental Security Income (SSI)?*

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:

(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.)

Drop files here or

Max. file size: 50 MB.

Applicant Employment Status

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

(Applicant)

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.

Please Select your Education Level:

Job Training/School Status

(Applicant)

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?*

(Applicant)

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.

Secondary Parent*

First name Last name

Date of Birth*

Month

Day

Year

Gender

Relationship to child:*

Please specify other relationship:

Married to Applicant:*

Secondary Parent Living in Household*

Cell Phone

(Secondary Parent)

Home Phone

(Secondary Parent)

Work Phone

(Secondary Parent)

Enter Email Confirm Email

Secondary Parent Living Address

Street Address Address Line 2 City State ZIP Code

Directions to Secondary Parent Home:

Secondary Parent Mailing Address Different from Living Address?

Secondary Parent Mailing Address

Address Line 1 Address Line 2 City State ZIP Code

Employment Status

(Secondary Parent)

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

Type of Income: Income Source 1

How often is the Secondary Parent paid? Income Source 1

Gross Amount per pay period: Income Source 1

(Secondary Parent)

Please upload supporting Secondary Parent 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)

Type of Income: Income Source 2*

How often is the Secondary Parent paid? Income Source 2

Gross Amount per pay period: Income Source 2

(Secondary Parent)

Please upload supporting Secondary Parent 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)

Type of Income: Income Source 3*

How often is the Secondary Parent paid? Income Source 3

Gross Amount per pay period: Income Source 3

(Secondary Parent/Guardian)

Please upload supporting Secondary Parent documentation: Income Source 3

Max. file size: 50 MB.

U.S. Military Status

(Secondary Parent)

How often are you paid Veterans Benefits?

(Secondary 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

(Secondary Parent)

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)

Secondary Parent need an interpreter?*

Preferred Language for Interpreter

Preferred Interpreter

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

(check all that apply)

Arabic

Bhutanese

Bosnian

Burmese

Chinese (Mandarin)

Chinese (Cantonese)

Dari

English

French

Karen (Burmese dialect)

Kirundi

Lingala

Maay Maay

Nepali

Pashto

Portuguese

Somali

Spanish

Swahili

Tagalog

Tigrigna

Vietnamese

Other

Please specify other language

Were you born in the U.S.?

(Refers to Secondary Parent)

Are you a current or former refugee?

(Refers to Secondary Parent)

Is the Applicant a minor?

Guardian's Name

(For Minor Applicant)

First Last

Guardian's Date of Birth

Month

Day

Year

Guardian's Living Address

Street Address City State ZIP Code

Guardian's Home Phone

Guardian's Cell Phone

Guardian's Work Phone

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Applicant*

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

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Adult*

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

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Adult*

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

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Adult*

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

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Adult*

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

Are there other persons living in the home with the Applicant who were NOT listed previously?*

Name*

First Last

Date of Birth

Month

Day

Year

Gender

Relationship to Adult*

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

Please use this space to tell us about any current circumstances affecting your family.

I give my permission to Champlain Valley Head Start or its funders/partners to use photos and/or video of me and/or family with the understanding that my family and I 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.*

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

Please Specify Other:

Authorized Representative (Optional)

Would you like to give permission to someone to speak with us on your behalf?

By providing an Authorized Representative you agree to the following:

I understand that I am not required to have an Authorized Representative. 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.

Authorized Representative Name

First Last

Authorized Representative Phone #

Authorized Representative Relationship to You

Authorized Representative Organization (if applicable)

Release of Information

Early Head Start (EHS) is a national program. 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 the expectant mother 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 expectant mother or family information to organizations or entities outside the organization.

Release for Pregnant Applicant (Legal Name)*

First Middle Last

Pregnant Applicant's Date of Birth

Month

Day

Year

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 District Office of the Family Services Division for the purpose of: • Obtaining documentation to determine eligibility for the Early Head Start program • Coordinating family safety/support services*

Other Organization

Please Specify Other

Legal Guardian Name (Printed)

(Legal Guardian Signature required if applicant is a minor)

First Last

Release Date*

MM slash DD slash YYYY

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

Early Head Start (EHS) is a national program. Federal regulations require that this program obtains documentation to facilitate up to date health requirements for pregnant women and any follow up care needed. Except as allowed in this authorization and release, CVHS will not communicate or disseminate any confidential expectant mother or family information to organizations or entities outside of CVHS.

Champlain Valley Head Start Authorization*

By checking this box, I, the Applicant/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 applicant 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
431 Pine Street, Suite 212
Burlington, VT 05401
(802) 651-4180 X215

I also consent to:
• Share and discuss results of my Early Head Start screenings screenings and health records with my health care providers and/or
state registries or CVHS collaborative partners in order to provide/support services for me or my family.
Share my prenatal assessment, enrollment and oral health status with WIC and its Public Health Dental Hygienists.
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.

Pregnant Applicant's Legal Name*

First Middle Last

Pregnant Applicant's Date of Birth

Month

Day

Year

Legal Guardian Name

(Legal guardian signature required if Applicant is a minor)

First Last

I am the:*

Health Release Date*

MM slash DD slash YYYY

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 applicant in the Early 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 applicant has been enrolled in the program, and the starting date for services.

Pregnant Applicant Name*

First Last

Legal Guardian Name

(If Applicant is a minor)

First Last

Consent for Services*

By checking this box, I, the Applicant or Parent/Guardian indicate my consent to the following:

• I intend to enroll in Early Head Start if I am 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.

Was this application completed with the help of another person other than the parent/guardian?

Who helped with the Application?

First Last

Organization (if applicable)

Pregnant Applicant or Parent/Guardian Signature

Date

Month

Day

Year

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.