Enrollment Application at Semcac

Head Start

Classroom-based Education
Home-based Education
Policy Council
Resources
Enrollment Application

Completing this application does not guarantee your enrollment. After completing the application, contact the Semcac office in your county (Semcac County Contact Center).

"*" indicates required fields

Step 1 of 5

20%

Family Information

Address of Residence*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If different than address of residence

What site/center are you applying for?

Are you enrolling any Foster Care children?*

Yes

If yes, please upload court documents or proof of Foster care payments*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB, Max. files: 10.

Phone Numbers

Home Phone*

Cell Phone

Work Phone

Guardian 1 Phone

Guardian 2 Phone

May we text you?*

Yes

Data/message rates may apply

Text

Add phone number

Your Email Address

Primary Language*

(At Home)

Interpreter needed:

Adult

Child

Marital Status*

Married

Separated

Divorced

Widowed

Single

Single living with Partner

Do any of the Applicants have an IEP or IFSP?*

Yes

If so, list names:

Do any of the Applicants receive SNAP (Supplemental Nutrition Assistance)?*

Yes

Do any of the Applicants receive WIC?*

Yes

If so, list names:

Do any of the Applicants have a chronic health problem?*

Yes

If so, list names and health problems:

Relative/Friend Contact

Please provide phone and contact information for a friend or relative

Phone

Name of Relative/Friend

Fill out the information below for EACH PERSON LIVING IN YOUR HOUSE.

Single parents: If a parent is not living in the household, you may mark the missing parent's info sections with "N/A" (Not applicable)

Mother or Guardian 1

Name*

First Last

Does this parent/guardian reside at the above mentioned household WITH the student?

Yes

Birth Date*

MM slash DD slash YYYY

If N/A for single father households, choose any date to bypass this section.

Sex*

Male

Female

Other

Race*

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity*

Hispanic

Non Hispanic

Unknown

Relationship to Mother/ Guardian 1*

Self

Spouse

Other Relative

Legal Guardian

Not Related

Relationship to Father/ Guardian 2*

Self

Spouse

Other Relative

Legal Guardian

Not Related

Option: Early Head Start - Pregnant Mom*

Yes

Due Date

* Due date is required for pregnant mothers.

Father or Guardian 2

Name*

First Last

Does this parent/guardian reside at the above mentioned household WITH the student?

Yes

Birth Date*

MM slash DD slash YYYY

If N/A for single mother households, choose any date to bypass this section.

Sex*

Male

Female

Other

Race*

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity*

Hispanic

Non Hispanic

Unknown

Relationship to Mother/Guardian 1/Foster Parent 1*

Self

Spouse

Other Relative

Legal Guardian

Not Related

Relationship to Father/Guardian 2/Foster Parent 2*

Self

Spouse

Other Relative

Legal Guardian

Not Related

Additional Household Member

Include all members that are living in the household, not just the applicants.

Name

First Last

Birth Date

MM slash DD slash YYYY

Sex

Male

Female

Race

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity

Hispanic

Non Hispanic

Unknown

Relationship to Mother/ Guardian 1

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Relationship to Father/ Guardian 2

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Classroom Preference

M - Morning class

A - Afternoon class

7hr - *Austin, Winona and Owatonna ONLY (Parent(s) working or going to school)

For Applicants Only

Program Options

HB/EHS - Home Based/Early Head Start

T/EHS - Toddler (24-33 months), for Winona & Austin only- Parent(s) working or in school

HS - Head Start

Applicants Only

Additional Household Member

Name

First Last

Birth Date

MM slash DD slash YYYY

Sex

Male

Female

Race

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity

Hispanic

Non Hispanic

Unknown

Relationship to Mother/ Guardian 1

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Relationship to Father/ Guardian 2

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Preference

M - Morning class

A - Afternoon class

7hr - *Austin, Winona and Owatonna ONLY (Parent(s) working or going to school)

Applicants Only

Program Options

HB/EHS - Home Based/Early Head Start

T/EHS - Toddler (24-33 months)

HS - Head Start

Applicants Only

Additional Household Member

Name

First Last

Birth Date

MM slash DD slash YYYY

Sex

Male

Female

Race

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity

Hispanic

Non Hispanic

Unknown

Relationship to Mother/ Guardian 1

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Relationship to Father/ Guardian 2

Self

Spouse

Birth Child

Step Child

Foster Child

Adopted Child

Other Relative

Legal Guardian

Not Related

Preference

M - Morning class

A - Afternoon class

7hr - *Austin, Winona and Owatonna ONLY (Parent(s) working or going to school)

Applicants Only

Program Options

HB/EHS - Home Based/Early Head Start

T/EHS - Toddler (24-33 months)

HS - Head Start

Applicants Only

Additional Household Member

Name

First Last

Birth Date

MM slash DD slash YYYY

Sex

Male

Female

Race

American Indian/ Alaska Native

Asian

Black African American

Multi-Racial/Biracial

Native Hawaiian/Other Pacific Islander

Other

Unspecified, N/A or Unknown

White

Please Specify Other

Ethnicity

Hispanic

Non Hispanic

Unknown

/Relationship to Mother/ Guardian 1

Self

Spouse

Birth Child