SmartForm HS Application OLMSTED English 2023-2024

"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

- Eureka Kids

-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, 2023
- 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, 2023
- 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
2023-24
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!
Is your mailing address the same as your home address?*

YesNo
Home Address for Your Family*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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.
Name of another contact person if we cannot reach you:*
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
Parent/Guardian #2 - Phone Number
Please enter a valid phone number.
Contact person's phone number:*
Please enter a valid phone number.
Contact person's relationship to you:*
Do you speak English?*

YESNO
Do you need an interpreter?*

YESNO
How well do you speak English?*

NoneLittleAverageVery 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?*

YesNo
Is your family expecting a baby?*

YESNO
If Yes, Include expected due date:

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

YESNO
Marital Status (choose one)*

MARRIEDMARRIED BUT LIVING APARTDIVORCEDWIDOWEDSINGLESINGLE LIVING WITH PARTNER
Who has custody of the child or children you are applying for?*
Type of medical insurance for each applicant:*

Blue PlusU CareNoneOther
Parent/Guardian #1 - Employment Status (check all that apply)

FULL TIMEPART TIMESEASONAL/ON-CALLRETIRED/DISABLEDTRAINING or SCHOOLMILITARYUNEMPLOYED
Parent/Guardian #1 - Employer / Company Name:
Parent/Guardian #1 Employment Date Started:

MonthDay 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:

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

HIGH SCHOOL DIPLOMA/GEDASSOCIATESBACHELORSNO EDUCATIONMASTERS or HIGHEREnter Completed Grade:
Parent/Guardian #1 - I AM ATTENDING SCHOOL (choose one)*

YESNO
Parent/Guardian #1 - My schooling and/or training is as follows: (provide specific details of your schooling or training)
Parent/Guardian #1 Name*

First Name Last Name
Parent/Guardian #1 from above (If living in the home)
Parent/Guardian #1 Sex*

MaleFemale
Parent/Guardian #1 Birth Date*

MonthDay Year
Date
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)*

HispanicNon-Hispanic
Is there a 2nd Parent/Guardian living in the home? (choose one)*

YESNO
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

MonthDay Year
Date
Parent/Guardian #2 Sex

MaleFemale
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)

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

FULL TIMEPART TIMESEASONAL/ON-CALLRETIRED/DISABLEDTRAINING or SCHOOLMILITARYUNEMPLOYED
Parent/Guardian #2 - (ONLY ANSWER IF living in the home) - Employer / Company Name:
Parent/Guardian #2 - (ONLY ANSWER IF living in the home) Employment Date Started:

MonthDay 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:

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

High School Diploma/GEDAssociatesBachelorsNo EducationMasters or HigherEnter completed grade:
Parent/Guardian #2 - I AM ATTENDING SCHOOL (choose one)

YES - I do attend schoolNO - 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)*

YESNO
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, 2023)
SR = School Readiness (for children age 3 or 4 on or before Sept. 1, 2023)
1. Child's Name*

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

MonthDay Year
Date
1. Child's Sex:*

MaleFemale
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)*

HispanicNon-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?*

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
1. Are you adding another child to this application?*

YesNo
2. Child's Name

First Name Last Name
2. Child's Birth Date

MonthDay Year
Date
2. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
2. Are you adding another child?

YesNo
3. Child's Name

First Name Last Name
3. Child's Birth Date

MonthDay Year
Date
3. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
3. Are you adding another child?

YesNo
4. Child's Name

First Name Last Name
4. Child's Birth Date

MonthDay Year
Date
4. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
4. Are you adding another child?

YesNo
5. Child's Name

First Name Last Name
5. Child's Birth Date

MonthDay Year
Date
5. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
5. Are you adding another child?

YesNo
6. Child's Name:

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

MonthDay Year
Date
6. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI would like my child to attend child care while I work or go to School
6. Are you adding another child?

YesNo
7. Child's Name:

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

MonthDay Year
Date
7. Child's Sex:

MaleFemale
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)

HispanicNon-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?

YesNo
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 programI would like my child to attend class Monday-Thursday 7:45am - 3:45pmI 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 relativeFamily member(s) with no health insuranceChild with a special need, IFSP or IEP (child name)Abuse of alcohol or drugs by either parentChild separated from parent due to jail/prison, military deployment or deportationRefugee status in last five yearsDeath of a child's parent or siblingFamily member with a mental health concernFamily violence or domestic abuse or order of protectionMoved many timesSerious medical condition or disability of child's parent or siblingChild Protection InvolvementSignificant decrease in family income within last 12 monthsNONE of these items are affecting my familyOther 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)Child Care AssistanceSSI (Supplemental Security Income)DWP (Diversionary Work Program)CASH Assistance from another stateRefugee Match GrantNONE 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?*
2022 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 StubsSelf EmploymentUnemployment CompensationRetirement/PensionVeterans BenefitsSocial SecurityNone of TheseOther
I received paychecks/pay stubs and I will (check all that apply)

I have a 2022 tax return and I will bring it to the Main Office for copyingI do NOT have a 2022 tax return, so I will turn in ALL W-2's from 2022A job was started in 2023. I will turn in 3 recent pay stubsI 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:

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Click on 'Browse Files' to browse your computer/device and select relevant income files for upload.
Cancelof
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 choiceSharing housing due to loss of housing or hardshipStaying at a shelter or Transitional HousingLiving in a hotel, motel, campground, car, etc.Home in foreclosure or getting evicted. Enter eviction dateOther/Additional Info
Foreclosure or eviction date

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

YesNo
My child(ren) stay(s) with a relative/friend/neighbor/caretaker or daycare center while I go to work or school:*

YesNo
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 ProgramEarly Childhood Special EducationSocial or Human Service AgencyChild Care ProgramCounty Public HealthFriends or FamilyEarly Childhood ScreeningHealth Care ProviderOther
Has your child/applicant completed an Early Childhood Screening?*

YesNo
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*

MonthDay Year
Date
Did someone help you complete this application?*

YESNO
If YES, name of person helping you:
May we contact this 'helper' person regarding this application?

YESNO
Phone Number of person helping you:
Please enter a valid phone number.
Fill out all information in the section below for EACH person living in your home.
Should be Empty: