Child's Name First Last Child's Date of Birth Month Day Year Primary Parent/Guardian's Name First Last Primary Parent/Guardian DOB Month Day Year 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.Amount of Child Support that you receive:How often do you receive Child Support?WeeklyBi-WeeklyMonthlyWhen did you begin receiving this Child Support Payment? Month Day Year Primary Parent/Guardian SignatureBy signing below, I certify that the information I have provided 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.Date Month Day Year Δ