HIPAA Form

By signing on the Parent/Guardian signature line below, I give my permission for my child to be transported in the event of an emergency. Additionally, I give my permission for my child to be released to the following people for the purposes of pick-up and/or transportation to/from CVHS activity sites. (Include the child’s other parent and other family members who may be likely to transport the child.) The parent/guardian understands that his/her child will only be released to persons identified on the following list. Anyone who is unknown to CVHS staff must show identification. I give my permission for my child to be transported to and from CVHS activities by any transportation service with whom CVHS may contract for transportation of children in the CVHS program, and to release the name and address of my child to transportation services contracted by CVHS for the purpose of CVHS activities. In the event of an emergency, I authorize the staff or collaborative partners of Champlain Valley Head Start to seek any necessary treatment or emergency medical care for my child.

Emergency Contact People must be able to transport the child in the event of an emergency if the CVHS parent or legal guardian cannot be reached. Emergency contacts must be aware they are designated as such. Emergency contacts unknown to CVHS staff must produce identification before a child is released.