Submit Interest Form - Champlain Valley Head Start

Submit Interest Form

Please Submit the Interest Form Below
(This is not an application)

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!

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*
Month
Day
Year
Applying for more than one child from the same family?
Child Name
First Last
Birthdate
Month
Day
Year
Program Option
Referred by another agency?
Referred by Name
First Last
Referred by Phone #
Comment
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Phone
This field is for validation purposes and should be left unchanged.