General Interest Form

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(This is not an application)

Please Submit the Interest Form Below

A Champlain Valley Head Start (CVHS) staff member will follow up with you within 10 days to begin the application process. Please note CVHS has limited enrollment opportunities which are filled based on child and family need.

We look forward to working with you!

"*" indicates required fields

Parent/Guardian Name*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email*

Language Spoken at Home*

English Proficiency*

Child Name*

First Last

Birthdate*

Applying for more than one child from the same family?

Child Name

First Last

Birthdate

Program Option

Referred by another agency?

Referred by Name

First Last

Referred by Phone #

Comment

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