Service/Health Provider Letter of Support

Service/Health Provider Letter of Support

Special Accommodations Grant (SAG)
You have received this form because a licensed child care, preschool, or afterschool program is seeking to apply for Special Accommodations Grant (SAG) funds through the Vermont Department for Children and Families (DCF), Child Development Division (CDD).

The SAG funding is designed to assist Vermont-licensed child care, preschool, or afterschool programs in creating a safe and inclusive environment by supporting children with disabilities or developmental delays in learning, growing, and playing alongside their peers.

The information provided on this form is used to verify that the program is caring for a child currently being supported by you or your agency and that you will assist the program in meeting the requirements of the grant application.

In addition to receiving this form, the program should have provided you with a consent form signed by the child's parent/legal guardian. If you did not receive a copy of the signed consent, please contact the program before completing this form.

This form is HIPAA-compliant; however, if you prefer to submit the form by another secure method, please click here to complete the PDF version of the form and electronically submit it to the child care provider, who will upload it with their complete SAG application.

If you have questions, please contact the program that made this request.
Contact Information
Child Care Program Name
Child's Name
Child Care Programs Email
example@example.com
Service Provider Name

First NameLast Name
Job Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Employers Name (if applicable)
Address of Your Work Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Support or Services Provided
Please tell us about the services/support you provide to the child named above.
In your work with the child care program on behalf of this child, have you made recommendations to the child care program?
If yes, of those recommendations, what has been implemented by the child care program and to what level?
Please list any additional recommendations for the child named above in their child care setting to help support their inclusion and greater involvement within the program (i.e., Additional staffing, equipment, training, etc.).
Certification
By submitting this form, you certify that the information provided is true and accurate.
Service Provider's Signature
Should be Empty:

Service/Health Provider Letter of Support

Contact Information

Support or Services Provided

Certification