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Head Start/Early Head Start English Online Application
Home
Early Childhood
Head Start/Early Head Start English Online Application
Head Start/Early Head Start English Online Application
Vision Design
"
*
" indicates required fields
Which program year are you applying for?
*
Select all that apply. You can apply for your child to attend for the remainder of this year and next year at the same time.
2023-2024 Program Year (September 2023-May 2024)
2024-2025 Program Year (September 2024-May 2025)
Which Head Start Center or Program are you applying for?
*
Select all that apply
Faribault Head Start Full Day Program
Faribault Head Start Morning Program
Faribault Head Start Afternoon Program
Lake City Head Start Half Day Program (morning) (2024-2025 only)
Northfield Head Start Full Day Program
Red Wing Head Start Morning Program
Red Wing Head Start Afternoon Program
Wabasha Head Start Half Day Program (morning) (2023-2024 only)
Zumbrota Head Start Half Day Program (morning)
Early Head Start Home Visiting Program (for ages 0-3)
About You
Answer the following questions about the primary parent or guardian. If you are applying for Early Head Start as a pregnant woman, please call (507) 696-1970 for a different application.
Full Legal Name
*
Birth Date
*
Month
Day
Year
Race
Gender
*
Female
Male
Other
Ethnicity
*
Hispanic
Not Hispanic
Do you receive income?
Yes
No
Native Language
What language do you normally speak at home?
English Skill Level
*
Very Well
Well
A Little
None
Do you need an interpreter to communicate in English?
Yes
No
Written Language
We can send home information in English or Spanish. Which language would you prefer?
English
Spanish
Contact Information
Cell Phone Number
Can we send you text messages?
*
Yes
No
Other phone number
If you do not have a cell phone, please give us another phone number where we can communicate with you.
Email
*
Preferred Method of Communication
*
Email
Text
Phone call
Home Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Mailing Address
If different than your home address.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
About your Head Start child
Answer the following questions about the child you would like to enroll in Head Start.
Full Legal Name
*
If your child has a middle name, include it. If your child has more than one last name, please include them both. Their name here should appear exactly as it does on their birth certificate. If they are a Junior , a III, etc. please also include that information as well.
Birth Date
*
Month
Day
Year
Gender
*
Female
Male
Other
Race
Ethnicity - Is your child Hispanic or Latino?
Yes
No
What language does your child speak at home?
*
Does your child have a diagnosed disability or a serious medical condition?
Yes
No
If yes, please explain:
Has your child completed Early Childhood Screening?
*
Early Childhood Screening should take place between the ages of 3 and 4. If your child has not completed his/her screening, please contact your local school district to schedule one.
Yes
No
Does your child have an IEP or IFSP through the school district?
*
If you say "Yes" please provide a copy of IEP or IFSP with the application
Yes
No
Do you have concerns about your child's development?
Yes
No
If yes, please explain:
Special Situations
Certain factors make a child automatically eligible for Head Start. Other factors give a child preference for enrollment. If any of the following apply to your family, please check the box and follow the directions given.
Categorical Eligibility
We are living in a motel, hotel, or campground because we cannot afford housing
We are living in an emergency or transitional shelter
We are sharing housing with another person or family because we lost or cannot afford our own housing
We are living in a vehicle at this time (any kind of vehicle)
We consider ourselves homeless
Child is a foster child
Child is in custody of a non-parent family member
Income
Please check all sources of income for you or anyone else in your household in the past year:
*
Wages/Salary
Cash Assistance (MFIP)
SSI (Supplemental Security Income)
Social Security Income (SSDI, RSDI, SSA)
DWP (Divisionary Work Program)
Self Employment or Farm Income
Unemployment
Long or Short-Term Disability
Child Support
SNAP/Food Support
Other
No Income in the past year
Who makes up your family?
Please count and list everyone who lives in your home at this time.
How many people live in your home?
*
Other Household Members
Please list ALL people living in your house right now, other than the primary parent/guardian and Head Start child listed above
Full Name
Date of Birth (ex. 1/10/2010, Month/Day/Year)
Relationship to the Head Start Child
Gender (Male or Female)
Race (AN=American Indian or Alaska Native, A=Asian, B=Black or African American, M=Multiracial or Biracial, N=Native Hawaiian or other Pacific Islander, O=Other, W=White)
Hispanic or Latino (Yes or No)
Does this person receive income? (Yes or No)
Add
Remove
If there are 2 adults living in the home, are you both the biological (or adopted) parents of the Head Start child?
*
Yes
No
Not Applicable
If there are 2 adults living in the home, are you legally married?
*
Yes
No
Not Applicable
Is anyone in the home pregnant?
*
Yes
No
Document Uploads
If you choose, you may upload your documentation here instead of bringing them to the center, mailing, emailing, or faxing them. This may be the quickest way to get your application completed.
Income Documents
Please provide proof of Cash Assistance (MFIP) or SSI, or court order of Foster Care placement. If your child is considered to be experiencing homelessness, contact 507-696-1970 for a separate form. If none of these situations apply, we need 12 months of income. You may provide proof of the last calendar year, in the form of your W-2 forms or your Income Tax Return. If you choose, you may provide proof of the last 12 months instead in the form of pay stubs. If you receive child support, please remember to turn in proof of the same 12 months of Child Support as the rest of your income.
Drop files here or
Select files
Accepted file types: gif, jpg, jpeg, png, pdf, doc, docx, , Max. file size: 64 MB.
Birthdate Proof Documents
For proof of your child's birthdate, we are able to accept his/her birth certificate, immunization record,, or just about any official document with their name and birthdate printed on it. We are not able to accept documents with handwritten birthdates.
Drop files here or
Select files
Accepted file types: gif, jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml, Max. file size: 64 MB.
IEP/ISFP Documentation
Please upload any active IEPs/IFSPs, child support documents, or any other requested documentation here
Drop files here or
Select files
Accepted file types: gif, jpg, jpeg, png, txt, rtf, html, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml, Max. file size: 64 MB.
Additional Information
Staff/Agency Assistance
Are you a staff member of an agency (Three Rivers, Social Services, Public Health, etc.) helping the applicant with this form? If so, please provide your name here.
How did you hear about us?
Data Privacy, Release of Information, Signature
Yes, I agree to the release of my information as outlined in the paragraph below. I understand my rights and responsibilities, and I certify that this information is true and accurate.
No, I do not wish to submit my child's application for Head Start at this time.
I give permission for Three Rivers Head Start to:
Share and exchange information about my child or family, including but not limited to: IEP/IFSP information, evaluations, name(s), phone number(s), and address(es) with my local school district, Public Health, or other outside agency/provider that I have indicated on this application. I understand this may be helpful in the application process and to coordinate services for my child.
Obtain, assess, and share information regarding my child with the local school district so that appropriate referrals and resources may be suggested. I understand that the process is to assist me in preparing my child for kindergarten.
Contact any or all of my income sources and to obtain information about my gross income. I understand this may assist in the application process and in determining my child’s eligibility for the Head Start program.
Remember: this is an application ONLY and does not guarantee enrollment in the program. Please keep Three Rivers Head Start informed of any changes in your address or phone number. Your right to privacy is protected by the Minnesota Privacy Act. Private information on the Head Start application will be used to determine your eligibility and for program planning. You are not legally required to provide this information.
I certify that the information that I have provided is true and complete to the best of my knowledge. I understand that providing incorrect information may disqualify my family from the program, and in some cases may constitute fraud.
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