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Head Start Program Application

You may complete an application by filling out the form below. Fill out as much information as possible. Fields marked with a red asterisk (*) are required. Click only once on the “Submit” button at the bottom of the form to send.

Important: We will contact every family who applies for Head Start. Please let us know of any changes to your address or phone number.

Applicant & Family Member Information

  • Contact Information

  • Emergency Contacts

  • Names and Phone Numbers of Other People if we Cannot Contact You
  • Emergency Contact #1
  • Emergency Contact #2
  • Emergency Contact #3
  • Family Information

  • Family Member Information

  • In addition to the required sections, fill out as many sections as necessary.
  • Only Family Members Living in Home
  • Primary Adult / Adult 1 (required)
  • Primary Adult / Adult 2
  • Please List All Other Family Members

  • For our purposes, a family is "all persons living in the same household who are (1) supported by the income of the parent(s) or guardian(s) of the child enrolling in the program, and (2) related to the parent(s) or guardian(s) by blood, marriage, or adoption."
  • Child (1) / Other Family Member (required)
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Child (2) / Other Family Member
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Child (3) / Other Family Member
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Child (4) / Other Family Member
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Child (5) / Other Family Member
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Child (6) / Other Family Member
    (If yes, and this is the potential Head Start child, please bring the child's IEP/IFSP with you when you complete your paperwork with Head Start staff.)
  • Only complete this section if this is the Head Start applicant:
  • Income

  • *** Proof of income is required with your application. Only applications with proof of income will be processed ***
  • Or Submit Income Documentation (We determine eligibility based on 12 months of income; it can be the previous year or the previous 12 months)

    > MFIP/TANF, GA, EA, DWP - a copy of your statement

    > Employed - a copy of all 2014 W-2's or 2014 Form 1040 Tax Return, Pay Stubs

    > Self-Employed - a copy of the first 2 pages of your 2014 Form 1040 Tax Return

    > Unemployment Compensation or Child Support - a printout of your payments from 1-1-14 to present

    > Social Security, SSI, Veterans Benefits, Workers Compensation - a letter from the funding agency

    > Financial Aid - a copy of your award letter for the last 2 semesters

    > Other income - Bring what you have

    > No Income? - Please call (507) 345-2410
  • Agency Specific Fields

  • Daycare

  • Housing

  • Family Type

  • Family Circumstances

  • Please read through the following list of possible family circumstances and check any that apply to your family. If "must be documented" is indicated, please bring the documentation with you when you complete your paperwork with Head Start staff.
  • Data Privacy Rights

  • Under current Federal and State legislation your right to privacy is protected. MVAC is asking you to supply us with private information concerning you, your family, and household. By Law you do not have to provide this information. MVAC needs information about you to determine if you can get help from any program. Without information about your household, MVAC may not be able to help you and the help may be late or less than what you may be eligible to receive. The purpose for this information is to inform you of eligibility for all programs at MVAC. MVAC may use information to research, plan, and evaluate programs. Information is used in determining compliance with Federal and State regulation's. MVAC will use this information to make statistical and demographic reports to different agencies and funding sources. Never will information that identifies you or any member of your household be revealed unless you give your written permission. MVAC will also use this information to develop a mailing list. MVAC will use the mailing list to update you on the programs and program changes. At no time will the mailing list be revealed to anyone outside MVAC. To assure that you are being served properly only MVAC Staff whose jobs require the information will have access to it.

    MVAC may share this information with state and local welfare agencies, community based organizations, local and state public and private human service agencies, the Minnesota Department of Employment and Economic Development, the Minnesota Department of Education, the United States Department of Labor, the United States Department of Health and Human Services and state and local educational programs, as allowed by law.

    This Agency will keep this information for seven years from the last date updated with you or until program audits are complete. You have the right to review your records at any time to request changes.
  • By initialing here you are indicating that you have read and understand the data privacy rights.
  • By initialing and submitting this application electronically I am certifying that the information I have provided is accurate to the best of my knowledge. I understand a completed application does not guarantee a place for my child in the program. Applications are reviewed at the Head Start Administrative Office. Parents are notified if their child has been selected.
  • Today's Date
  • Submitting this application is step one toward applying for Head Start. In order to complete the application process you will also need to:

    1. Submit proof of income
    2. Submit proof of child's age (birth certificate, immunization record, insurance card)

    If we need more information to process this application we will contact you.
  • This field is for validation purposes and should be left unchanged.