Head Start/Early Head Start 2017-2018 English Online Application

Use this application to apply for your child to enter Head Start or Early Head Start.

Select all that apply
About You!
Answer the following questions about the primary parent or guardian.
What language do you normally speak at home?
We can send home information in English or Spanish. Which language would you prefer?
Contact Information
If you do not have a cell phone, please give us another phone number where we can communicate with you.
About your Head Start child!
Answer the following questions about the child you would like to enroll in Head Start.
If your child does not normally go by his/her full legal name, what name do they use? (ex. Michael David Johnson-Anderson is his legal name, but he goes by Mikey Johnson)
Which race(s) best describe(s) your child's heritage?
If you say "Yes" please provide a copy of IEP or IFSP with the application
Please upload a copy of your child's most recent IEP or IFSP. If you do not have a copy right now, please send one to us as soon as possible. You can drop it off at your nearest Head Start Center, email it to jgonzalezdiaz@threeriverscap.org, fax it to 507-732-8547 attn: Head Start Enrollment, or mail it to Three Rivers Community Action Inc. Attn: Head Start Enrollment 1414 Northstar Drive, Zumbrota, MN 55992. We are not able to complete your child's application and/or offer enrollment until we have this documentation.
Files must be less than 64 MB.
Allowed file types: gif jpg jpeg png.
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.
Address
If you have a separate mailing address, select "no" and please enter your mailing address.
Mailing Address
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.
Please select the county which issues your cash assistance. Provide proof of your cash benefit for this month or last month. You can drop it off at your closest Head Start center, email it to jgonzalezdiaz@threeriverscap.org, fax it to 507-732-8547 attn: Head Start Enrollment, or mail it to Three Rivers Community Action, Inc. Attn: Head Start Enrollment 1414 Northstar Drive Zumbrota, MN 55992. Your application is not complete and cannot be processed until we receive this proof. You do not need to provide proof of any other income.
Please enter the full name of the family member receiving SSI. Provide proof of his/her current SSI benefit. You can drop it off at your closest Head Start center, email it to jgonzalezdiaz@threeriverscap.org, fax it to 507-732-8547 attn: Head Start Enrollment, or mail it to Three Rivers Community Action, Inc. Attn: Head Start Enrollment 1414 Northstar Drive Zumbrota, MN 55992. Your application is not complete and cannot be processed until we receive this proof. You do not need to provide proof of any other income.
Please upload the court order placing your child into foster care. You do not need to provide any income information, as being a foster child makes your child automatically eligible for Head Start. If you cannot scan and upload the document, you can drop it off at your closest Head Start center, email it to jgonzalezdiaz@threeriverscap.org, fax it to 507-732-8547 attn: Head Start Enrollment, or mail it to Three Rivers Community Action, Inc. Attn: Head Start Enrollment 1414 Northstar Drive Zumbrota, MN 55992. Your application is not complete and cannot be processed until we receive this proof.
Files must be less than 16 MB.
Allowed file types: gif jpg jpeg png bmp tif pdf doc docx.
Please describe your family's situation.
Please provide the former Head Start child's name, date of birth, when they attended, and which program they attended. This does not make your child automatically eligible, however it does give them preference for selection for the program.
Who makes up your family?
Please count and list everyone who lives in your home at this time.
Person 1
Head of Household or primary parent/guardian - Information already entered above
Person 2
Head Start Child - Information already entered above.
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
How is this person related to YOU?
Does this person have income of any type?
If yes, please provide proof of all payments received in 2017 or in the past 12 months in the upload field at the end of this form.
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Has your child experienced any of the following situations? You do not have to answer this question, but it does allow us to better help your family. In addition, we may be able to prioritize your child for enrollment based on your answers to this question. Your child will not be penalized, however, if you choose not to answer.
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.
If you do not receive Cash Assistance or SSI, and your child cannot be considered homeless or in Foster Care, we will need proof of 12 full months of income for everyone in your household. 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 to provide your tax return, we ONLY need the actual return, the form 1040 or 1040A which should be one page front and back. We do NOT need all the additional schedules and paperwork that go along with the return.) If you choose, you may provide proof of the last 12 months instead. To calculate which 12 months you would need, look at today's date. Your 12 month period would start from the first day of the month we are in, LAST YEAR, and end on the last day of last month. Example: Today is February 14th, 2017. My 12 month period would start February 1st, of the current year and end on January 31st, of the following year. (For example, in 2018, the 12th month period would start February 1st 2017 and end January 31st, 2018) 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.
Files must be less than 64 MB.
Allowed file types: gif jpg jpeg png pdf.
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. You may upload your document here instead of dropping it off, emailing it, mailing it, or faxing it. This is the quickest way to complete your application.
Files must be less than 64 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.
Please upload any active IEPs/IFSPs, child support documents, or any other requested documentation here
Files must be less than 2 MB.
Allowed file types: txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.

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.

Please type your full, legal name. This shall be treated as if it were your signature on a paper application.