This application signifies the family’s desire to enroll this child in the Early Head Start or 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 child has been enrolled in the program, and the starting date for services.
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.
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.
Please complete the following health information and review our HIPAA policy at the end of this form.
Champlain Valley Head Start recognizes that not all families have formal documentation of child support, such as court orders or documentation from the Office of Child Support. Please complete the following statement in order to self-declare the child support you receive. Be sure to include all child support received, even if it is not for the child who is applying to enroll in the program.
This application signifies the family’s desire to enroll this child in the Early Head Start or 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 child has been enrolled in the program, and the starting date for services.
255 South Champlain St.
Burlington, VT 05401
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