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Head Start Application

Head Start Application

Step 1 of 5

20%

Family Information
Address of Residence*
Street Address Address Line 2 City State ZIP Code
Mailing Address
(If Different)
Are you enrolling any Foster Care children?*
- Yes
- No
If yes, please upload court documents or proof of Foster care payments*
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Phone Numbers
Home Phone*
Cell Phone
Work Phone
Guardian 1 Phone
Guardian 2 Phone
May we text you?*
- Yes
- No
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
- No
If so, list names:
Do any of the Applicants receive WIC?*
- Yes
- No
If so, list names:
Do any of the Applicants have a chronic health problem?*
- Yes
- No
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
- No
Email
Birth Date*
Date Format: 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
- No
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
- No
Email
Birth Date*
Date Format: 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*
- Self
- Spouse
- Other Relative
- Legal Guardian
- Not Related
Relationship to Father/ Guardian 2*
- Self
- Spouse
- Other Relative
- Legal Guardian
- Not Related
Additional Household Member
Name
First Last
Email
Birth Date
Date Format: 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)
- HS - Head Start
Applicants Only
Additional Household Member
Name
First Last
Email
Birth Date
Date Format: 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
Email
Birth Date
Date Format: 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
Email
Birth Date
Date Format: 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
Are there additional children living in your household than could be entered on this application?
- YES (We will follow up with you)

Mother/Guardian 1 Personal Information
Employment Status Mother/Guardian:*
- Full-time (35 hrs./week or more)
- Part-Time (under 35 hrs./week)
- Seasonal
- Retired/Disabled
- Training or School
- Unemployed
- Unknown or N/A
Highest level of Education for Mother/Guardian:*
- Less than High School Graduate
- An Associated Degree, Vocational School, or some College
- A High School Graduate or GED
- An Advanced Degree or Baccalaureate Degree
- Unknown or N/A
Member of US Military*
- Yes
- No
- Unknown
Veteran US Military*
- Yes
- No
- Unknown
Disabled*
- Yes
- No
- Unknown
Insurance Type*
- Medicaid
- Medicare
- Minnesota Care
- Private
- None
- Unknown
Check all that apply
Housing Arrangements*
- Rent
- Own
- Shelter
- Homeless
- Other
- Unknown
Check all that apply
Father/Guardian 2 Personal Information
Employment Status Father/Guardian:*
- Full-time (35 hrs./week or more)
- Part-Time (under 35 hrs./week)
- Seasonal
- Retired/Disabled
- Training or School
- Unemployed
- Unknown
Highest level of Education for Father/Guardian:*
- Less than High School Graduate
- An Associated Degree, Vocational School, or some College
- A High School Graduate or GED
- An Advanced Degree or Baccalaureate Degree
- Unknown
Member of US Military*
- Yes
- No
Veteran US Military*
- Yes
- No
- Unknown
Disabled*
- Yes
- No
- Unknown
Insurance Type*
- Medicaid
- Medicare
- Minnesota Care
- Private
- None
- Unknown
Check all that apply
Housing Arrangements*
- Rent
- Own
- Shelter
- Homeless
- Other
- Unknown
Check all that apply
Are any of the applicants listed CURRENTLY enrolled in EHS?*
- Yes
- No
If yes, name/where*
Please mark any Special Considerations listed below that pertain to your family
- Homeless (Questionnaire attached)
- Current Teen parent
- Incarcerated Parent
- Family with 3 or more children under the age of 5
- Parent has a documented disability or mental health diagnosis
- No caregiver present because parent(s) working and/or in job training/education for 6 hours or more per day
- Over income returning child
- Current or history of drug/alcohol abuse
- Foster care
- First time parent
- Death of child’s parent or sibling
- Child does not reside with biological parent(s). Instead relative/friend (Not Foster Care)
- Documented public school, community agency or health professional referral
- Family previously enrolled in the program
- Current or history of domestic violence
- Refugee camp – within last 5 years.

Verification of Family Income
I have provided the following document(s) to verify my family income:*
- Pay Stubs (12 Months)
- W-2(s) (Previous Year)
- Child Support (previous year)
- Income Self Declaration
- Request for Income Verification, submitted to employer/agency.
- Form 1040 (Previous Year)
- Court Documents: Foster Child
- Unemployment Benefits
- TANF/MFIP (must show currently on)
- SSI for a Disability (must show currently on)
- Homeless/McKinney-Vento Act Questionnaire
All income MUST be for the same 12 month time period.
Upload files from selected documents
Accepted file types: jpg, gif, png, pdf.
The checked forms are attached:*
- Yes
- No
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.
Who referred you or how did you learn about our program?
- Child Care Program
- Early Childhood Screening
- Health Care Provider
- Semcac website
- Social or Human Service Agency
- Family or Friend
- Word of Mouth
- Brochure or poster
- Adult Basic Education or other Adult Literacy Program
- Early Childhood Special Education
- Parent(s) or sibling(s) previously participated in program
- Other
Mark all that apply.
If other, please specify
Thank you for this information. It helps in our recruitment efforts to reach families most in need.

1. I have received a copy of “Semcac Data Privacy Notice”.*
- Yes
- No
Read Privacy Statement"
2. I give permission for Head Start to release my child/children’s name, parent(s) name, phone number and address to his/her local school district*
- Yes
- No
I give permission for Head Start to Release or Obtain preschool screening records
- Release
- Obtain
Child's Name
First Last
3. I understand by completing this application it does not guarantee my child will be accepted into the program.*
- Yes
- No
4. A copy of the applying child /children’s Immunization record is attached.*
- Yes
- No
Upload Immunization Record
Accepted file types: jpg, gif, png, pdf.
5. If you are not eligible for Head Start may we share your application with other Childcare Programs in our area that you may qualify for?*
- Yes
- No
Additional information we need to know about your application?
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.
Parent/Guardian Signature*
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*
Date Format: MM slash DD slash YYYY
Upload Delegations of Powers by Parent Form
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

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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

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