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Head Start Application

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Head Start Application

Step 1 of 5

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  • Family Information

  • (If Different)
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.
  • Phone Numbers

    Data/message rates may apply
  • Add phone number
  • (At Home)
  • Relative/Friend Contact

    Please provide phone and contact information for a friend or relative
  • 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

  • Date Format: MM slash DD slash YYYY
    If N/A for single father households, choose any date to bypass this section.
  • * Due date is required for pregnant mothers.
  • Father or Guardian 2

  • Date Format: MM slash DD slash YYYY
    If N/A for single mother households, choose any date to bypass this section.
  • Additional Household Member

  • Date Format: MM slash DD slash YYYY
    For Applicants Only
    Applicants Only
  • Additional Household Member

  • Date Format: MM slash DD slash YYYY
    Applicants Only
    Applicants Only
  • Additional Household Member

  • Date Format: MM slash DD slash YYYY
    Applicants Only
    Applicants Only
  • Additional Household Member

  • Date Format: MM slash DD slash YYYY
    Applicants Only
    Applicants Only
  • Mother/Guardian 1 Personal Information

    Check all that apply
    Check all that apply
  • Father/Guardian 2 Personal Information

    Check all that apply
    Check all that apply
  • Verification of Family Income

    All income MUST be for the same 12 month time period.
  • Accepted file types: jpg, gif, png, pdf.
  • Family

    For the purposes of eligibility, Family, for a child, means all persons living in the same household who are: (1) Supported by the child’s parent(s) or guardian(s)’ income; and (2) Related to the child’s parent(s) or guardian(s) by blood, marriage or adoption; or (3) The child’s authorized caregiver or legally responsible party. Family, for a pregnant woman, means all persons who financially support the pregnant woman.
    Mark all that apply.
  • Thank you for this information. It helps in our recruitment efforts to reach families most in need.
    Read Privacy Statement"
  • Accepted file types: jpg, gif, png, pdf.
  • The information provided is accurate and true. I give Semcac Head Start permission to verify all of the above information.
    I further understand that Head Start is a service paid for with federal and state funds and providing inaccurate, misleading, or untruthful information could have serious legal consequences for me.
  • Please Type your name to signify your signature. If signer is not biological mother or father, attach completed Delegation of Powers by Parent form.
  • Date Format: MM slash DD slash YYYY
  • Accepted file types: jpg, gif, png, pdf.
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Questions? Contact Information for Head Start – located in 6 counties, below.

County Phone 
Dodge County 507.634.4350
Fillmore County 507.765.2761
Houston County 507.725.3677
Mower County 507.433.5889
Steele County 507.451.7134
Winona County 507.452.8396

Head Start

  • Head Start
  • Head Start Services
  • Resources & Links
  • FAQs

Contact A Semcac Office

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semcac@semcac.org
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Serving Southeastern Minnesota Counties

Dodge, Fillmore, Freeborn, Houston, Mower, Winona & Steele | Limited services in Olmsted, Goodhue, Rice, Wabasha & Waseca  View the list of services offered in each county.

750

2019 Annual Report

An Equal Opportunity Employer • Member of the Rushford Area Chamber of Commerce
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