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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, Max. file size: 50 MB, Max. files: 10.
    • 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

    • 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

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

      Include all members that are living in the household, not just the applicants.
    • MM slash DD slash YYYY
      For Applicants Only
      Applicants Only
    • Additional Household Member

    • MM slash DD slash YYYY
      Applicants Only
      Applicants Only
    • Additional Household Member

    • MM slash DD slash YYYY
      Applicants Only
      Applicants Only
    • Additional Household Member

    • 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, Max. file size: 50 MB.
    • Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
    • Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
    • Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
    • 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, Max. file size: 50 MB.
    • 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.
    • MM slash DD slash YYYY
    • Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
    [/raw]




    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

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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.

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