SmartForm HS Application Olmsted English 2022-2023

"Ensuring positive beginnings for all young children and their families."
Families First of Minnesota is an equal opportunity provider and employer.

Providing Free or Low Cost Quality Early Learning Services in Olmsted County

Please fill out the application, electronically sign and date the application and make sure to either upload proof of income in the form areas below where requested OR email proof of all income to: anitah@familiesfirstmn.org

Applications are also available at www.familiesfirstmn.org

Alternately, you can Email, Mail or Deliver completed Application and Proof of Income to:
Families First Head Start
126 Woodlake DR SE, Rochester, MN 55904
(A drop box is available and located on the northwest corner of the building for use after office hours.)

Please keep this page for your reference.
Income qualifying children and families with the greatest need have the highest priority for enrollment. Placements are made according to child and family needs, parent choice, and available openings. Head Start will do its best to enroll your child, but space is limited. IMPORTANT: We will contact every family who applies for Head Start.
Please tell us if your phone number or address changes.

Early Head Start is:
- For pregnant mothers infants and toddlers under age 3
- If accepted, this all-year program will be no cost to your family - Available options include:
Home Based option: Weekly home visits and 2 times per month and Family Engagement Hour
Center Based option: Monday through Thursday for 6 weeks to 3 years old. Monthly Home Visits
Child Care Partnerships: Monday through Friday with monthly home visits

- Good News Children’s Center
- First Steps Academy
- Rochester Alternative Learning Center

Services provided for children with special needs

Head Start is:
- For children who are 3 or 4 on or before September 1, 2022
- If accepted, this program will be no cost to your family
- Buses are available to SOME areas
- Classes runs 4 days per week
- Services provided for children with special needs
School Readiness is:
- For children who are 3 or 4 on or before September 1, 2022
- If accepted, School Readiness gives your child a scholarship to help pay for a preschool program
- You will decide which preschool program is right for your family
- Families drive their child to and from school
- Classes may run 2, 3, 4 or 5 days per week depending on the school you choose
If you need help or have questions, please call us:

English call 507.287.2009
Español call 507-287-2009
Arabic and (Soomaaliga) Somali call 507-287-2009
Toll Free call 1.800.462.1660
DATA PRIVACY RIGHTS OF APPLICANTS OF FAMILIES FIRST OF MINNESOTA, INC.
EARLY HEAD START AND HEAD START

RIGHT TO KEEP INFORMATION ABOUT YOU PRIVATE (DATA PRIVACY)

Most of the information we collect about you will be classified as private. That means you and the agency collecting the data can see it; others cannot. Occasionally, statistics and other anonymous data will be taken from the information we collect about you or your family. This is public and open to anyone, but it will not identify you in any way.
In a few cases, information we collect is classified confidential. Confidential data is not open to anyone (not even you) except the government agencies that need it. Data in this category deals with civil or criminal investigation, some medical data, and the names of persons who report child or vulnerable adult abuse.

PURPOSE OF INFORMATION

The information you are asked to provide will be used to determine program eligibility, to coordinate services between programs, to verify program services being provided, and to provide us with a mailing list. This list will be used to update you on upcoming programs and program changes and to inform you of eligibility for programs within Families First of Minnesota. Only Head Start or School Readiness Families First staff and funding source employees whose jobs require access to this information, as well as Federal or State Auditors, may have access to your information.

RIGHT TO ACCESS YOUR RECORDS

Access by you. You can see all public and private records about yourself and your children. To see your file, call Families First of Minnesota during agency hours and make a request to review your files within five working days by contacting the program from which you are receiving service. Review will take place on site during working hours.

Access by agency. Employees of this agency will have access to information about you any time their work requires it. By law, some other government and contractor agencies will also have access to certain information about you if they provide a service to you or if they provide a service to this agency that affects you and requires access to your records. They may include school districts, public health, social services and financial assistance.
FAMILIES FIRST OF MINNESOTA
Application for Early Head Start, Head Start in Olmsted County
2022-23
126 Woodlake DR SE, Rochester, MN 55904
Phone (507)287-2009 or 1 (800) 462-1660
Fax (507) 287-2411
If you need help, please call us!
Home Address for Your Family *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is your mailing address the same as your home address? *

Yes No
Mailing Address IF DIFFERENT than Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian #1 - Phone Number *
Please enter a valid phone number.
Parent/Guardian #2 - Phone Number
Please enter a valid phone number.
Name of another contact person if we cannot reach you: *
Contact person's relationship to you: *
Contact person's phone number: *
Please enter a valid phone number.
Your Email Address (use format: example@example.com)
PLEASE NOTE: BY ENTERING YOUR EMAIL ADDRESS, WE WILL SEND YOU A COMPLETED COPY OF YOUR SUBMITTED APPLICATION IN PDF FORMAT VIA EMAIL
Do you speak English? *

YES NO
Do you need an interpreter? *

YES NO
How well do you speak English? *

None Little Average Very Well
Language Spoken at Home *
Number of people living in your home: *
Number of people in your family: *
Can you take your child to and from school if a bus is not available? *

Yes No
Is your family expecting a baby? *

YES NO
If Yes, Include expected due date:

Month Day Year
Date
Would you like monthly prenatal home visits and weekly home visits when the baby is born?

YES NO
Who has custody of the child or children you are applying for? *
Marital Status (choose one) *

MARRIED MARRIED BUT LIVING APART DIVORCED WIDOWED SINGLE SINGLE LIVING WITH PARTNER
Type of medical insurance for each applicant: *

Blue Plus U Care None Other
Parent/Guardian #1 - Employment Status (check all that apply)

FULL TIME PART TIME SEASONAL/ON-CALL RETIRED/DISABLED TRAINING or SCHOOL MILITARY UNEMPLOYED
Parent/Guardian #1 - Employer / Company Name is (permanent, seasonal or on-call):
Parent/Guardian #1 Employment Date Started:

Month Day Year
Date
Parent Guardian #1 - I work seasonally or on-call and I work when ... (explain when you have the opportunity to work)
Parent/Guardian #1 - If unemployed, enter last date worked:

Month Day Year
Date
Parent Guardian #1 - If unemployed, explain why:
Parent/Guardian #1 - Highest Level of Education *

HIGH SCHOOL DIPLOMA/GED ASSOCIATES BACHELORS NO EDUCATION MASTERS or HIGHER Enter Completed Grade:
Parent/Guardian #1 - I AM ATTENDING SCHOOL (choose one) *

YES NO
Parent/Guardian #1 - My schooling and/or training is as follows: (provide specific details of your schooling or training)
Is there a 2nd Parent/Guardian living in the home? (choose one) *

YES NO
Fill out all information in the section below for EACH person living in your home.
Parent/Guardian #1 from above (If living in the home)
Parent/Guardian #1 Name *

First Name Last Name
Parent/Guardian #1 Birth Date *

Month Day Year
Date
Parent/Guardian #1 Sex *

Male Female
Parent/Guardian #1 Race (Enter code) *
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
Parent/Guardian #1 Ethnicity (check one) *

Hispanic Non-Hispanic
Parent/Guardian #2 from above (complete these questions starting with "Parent/Guardian #2" ONLY IF THEY ARE LIVING IN THE HOME)
Parent/Guardian #2 Name

First Name Last Name
Parent/Guardian #2 Birth Date

Month Day Year
Date
Parent/Guardian #2 Sex

Male Female
Parent/Guardian #2 Race (Enter code)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
Parent/Guardian #2 Ethnicity (check one)

Hispanic Non-Hispanic
Parent/Guardian #2 - Employment Status (check all that apply)

FULL TIME PART TIME SEASONAL/ON-CALL RETIRED/DISABLED TRAINING or SCHOOL MILITARY UNEMPLOYED
Parent/Guardian #2 - (ONLY ANSWER IF living in the home) - Employer / Company Name is (permanent, seasonal or on-call):
Parent/Guardian #2 - (ONLY ANSWER IF living in the home) Employment Date Started:

Month Day Year
Date
Parent/Guardian # 2 (ONLY ANSWER IF living in the home) - I work seasonally or on-call and I work when ... (explain when you have the opportunity to work)
Parent/Guardian #2 - If unemployed, enter date last worked:

Month Day Year
Date
Parent/Guardian #2 - If unemployed, explain why:
Parent/Guardian #2 - Highest Level of Education:

High School Diploma/GED Associates Bachelors No Education Masters or Higher Enter completed grade:
Parent/Guardian #2 - I AM ATTENDING SCHOOL (choose one)

YES - I do attend school NO - I do not attend school
Parent/Guardian # 2 - My schooling and/or training is as follows: (provide specific details of your schooling or training)
Are there more adults living in the home? ... (choose one) *

YES NO
If YES, please describe/explain the other adults living in the home:
Please enter ALL children in the home, whether or not you are applying for them to be in our programs ...
CHOOSE the program any applicant is applying for. Programs you can apply for:
EHS = Early Head Start (for pregnant mothers and children under age 3)
HS = Head Start (for children age 3 or 4 on or before Sept. 1, 2022)
SR = School Readiness (for children age 3 or 4 on or before Sept. 1, 2022)
1. Child's Name *

First Name Last Name
1. Child's Birth Date *

Month Day Year
Date
1. Child's Sex: *

Male Female
1. Child's Race (Enter letter code from choices) *
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
1. Ethnicity (check one) *

Hispanic Non-Hispanic
1. This child's relationship to 1st Parent/Guardian listed: *
1. This child's relationship to 2nd Parent/Guardian listed: *
1. Are you applying to any of our programs for this child? *

Yes No
1. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
1. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
1. Are you adding another child to this application? *

Yes No
2. Child's Name

First Name Last Name
2. Child's Birth Date

Month Day Year
Date
2. Child's Sex:

Male Female
2. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
2. Ethnicity (check one)

Hispanic Non-Hispanic
2. This child's relationship to 1st parent listed: *
2. This child's relationship to 2nd parent listed:
2. Are you applying to any of our programs for this child?

Yes No
2. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
2. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
2. Are you adding another child?

Yes No
3. Child's Name

First Name Last Name
3. Child's Birth Date

Month Day Year
Date
3. Child's Sex:

Male Female
3. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
3. Ethnicity (check one)

Hispanic Non-Hispanic
3. This child's relationship to 1st parent listed:
3. This child's relationship to 2nd parent listed:
3. Are you applying to any of our programs for this child?

Yes No
3. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
3. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
3. Are you adding another child?

Yes No
4. Child's Name

First Name Last Name
4. Child's Birth Date

Month Day Year
Date
4. Child's Sex:

Male Female
4. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
4. Ethnicity (check one)

Hispanic Non-Hispanic
4. This child's relationship to 1st parent listed:
4. This child's relationship to 2nd parent listed:
4. Are you applying to any of our programs for this child?

Yes No
4. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
4. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
4. Are you adding another child?

Yes No
5. Child's Name

First Name Last Name
5. Child's Birth Date

Month Day Year
Date
5. Child's Sex:

Male Female
5. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
5. Ethnicity (check one)

Hispanic Non-Hispanic
5. This child's relationship to 1st parent listed:
5. This child's relationship to 2nd parent listed:
5. Are you applying to any of our programs for this child?

Yes No
5. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
5. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
5. Are you adding another child?

Yes No
6. Child's Name:

First Name Last Name
6. Child's Birth Date:

Month Day Year
Date
6. Child's Sex:

Male Female
6. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
6. Ethnicity (check one)

Hispanic Non-Hispanic
6. This child's relationship to 1st parent listed:
6. This child's relationship to 2nd parent listed:
6. Are you applying to any of our programs for this child?

Yes No
6. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
6. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
6. Are you adding another child?

Yes No
7. Child's Name:

First Name Last Name
7. Child's Birth Date:

Month Day Year
Date
7. Child's Sex:

Male Female
7. Child's Race (Enter letter code from choices)
NA/AN-American Indian/Alaska Native A=Asian B=Black or African American NH/PI=Native Hawaiian/Other Pacific Islander W=White M=Multiracial
7. Ethnicity (check one)

Hispanic Non-Hispanic
7. This child's relationship to 1st parent listed:
7. This child's relationship to 2nd parent listed:
7. Are you applying to any of our programs for this child?

Yes No
7. If yes, choose which program applying for:

Early Head Start (EHS) Head Start (HS) School Readiness (SR)
7. If you have chosen Early Head Start (EHS) program for your child, choose ALL that apply:

I am interested in the weekly home visit program I would like my child to attend class Monday-Thursday 8:00am - 3:30pm I would like my child to attend child care while I work or go to School
Please check below ALL items affecting your family. This helps us to understand your family's needs and priority for enrollment. *

Foster child or child in custody of a relative Family member(s) with no health insurance Child with a special need, IFSP or IEP (child name) Abuse of alcohol or drugs by either parent Child separated from parent due to jail/prison, military deployment or deportation Refugee status in last five years Death of a child's parent or sibling Family member with a mental health concern Family violence or domestic abuse or order of protection Moved many times Serious medical condition or disability of child's parent or sibling Child Protection Involvement Significant decrease in family income within last 12 months NONE of these items are affecting my family Other difficulties causing great stress (please explain):
If there is a child with a special need, IFSP or IEP - please include child's name below.
Check any of the following your family received within the last 6 months: *

MFIP (CASH Assistance) SNAP (Food Benefits) WIC (Public Health Food Program) Child Care Assistance SSI (Supplemental Security Income) DWP (Diversionary Work Program) CASH Assistance from another state Refugee Match Grant NONE of these
If you receive MFIP (Cash Assistance), Child Care Assistance, SSI, DWP, or Refugee Match, from which county do you receive this?
What is the monthly amount of your family income before taxes? *
2021 INCOME IS REQUIRED WITH YOUR APPLICATION TO DETERMINE ELIGIBILITY. IF YOU HAVE QUESTIONS ON INCOME CALL: 507-287-2009
Check off those incomes you have received during the last year:

Pay Checks/Pay Stubs Self Employment Unemployment Compensation Retirement/Pension Veterans Benefits Social Security None of These Other
I received paychecks/pay stubs and I will (check all that apply)

I have a 2021 tax return and I will bring it to the Main Office for copying I do NOT have a 2021 tax return, so I will turn in ALL W-2's from 2021 A job was started in 2022. I will turn in 3 recent pay stubs I have a digital copy of my income - I will attach it here. (File types for upload include PDF, DOC/DOCX, JPG/JPEG or PNG only)
Attach your file(s) HERE:

Click on 'Browse Files' to browse your computer/device and select relevant income files for upload.
Cancel of
For other incomes, indicate how you will get the information to us :
What is your current living situation? (choose one) *

Own, rent or share housing by choice Sharing housing due to loss of housing or hardship Staying at a shelter or Transitional Housing Living in a hotel, motel, campground, car, etc. Home in foreclosure or getting evicted. Enter eviction date Other/Additional Info
Foreclosure or eviction date

Month Day Year
Date
My child(ren) stay(s) home all day *

Yes No
My child(ren) stay(s) with a relative/friend/neighbor/caretaker or daycare center while I go to work or school: *

Yes No
If yes to above question, name and address of care provider (daycare/relative/neighbor/caretaker):
If yes, what hours during the week is your child in care?
Who referred you to our program? (Check all that apply) *

Adult Basic Education or other Adult Literacy Program Early Childhood Special Education Social or Human Service Agency Child Care Program County Public Health Friends or Family Early Childhood Screening Health Care Provider Other
Has your child/applicant completed an Early Childhood Screening? *

Yes No
My applicant child, enter child name has completed an Early Childhood Screening at enter school district on Date of Screening .
I give permission to exchange information with Early Childhood Screening. I give permission to Families First of Minnesota, Head Start and School Readiness to verify any county public assistance and/or child support that I receive. I give permission to exchange my child/family information which may include health, school, work, attendance, parent share, developmental and enrollment information with Families First of MN partner programs. To the best of my knowledge, the information I have given is accurate and true. Authorization is valid for one calendar year from the date of signature.
Parent/Guardian Signature *

Clear
Enter your Name *
Today's Date *

Month Day Year
Date
Did someone help you complete this application? *

YES NO
If YES, name of person helping you:
May we contact this 'helper' person regarding this application?

YES NO
Phone Number of person helping you:
Please enter a valid phone number.
Should be Empty: