Three Rivers Head Start/Early Head Start English Online Application
Program Options
Which school year are you applying for? Select all that apply. You can apply for your child to attend for the remainder of this year and next year at the same time if there are multiple options. We accept applications all year, even if the school year has started.
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2024-2025 (September 2024-May 2025)
Which Head Start Center or Program are you applying for? Select all that apply.
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Faribault Full Day
Faribault Morning
Faribault Afternoon
Northfield Full Day
Red Wing Morning
Red Wing Afternoon
Lake City Morning
Zumbrota Morning
Early Head Start Home Visiting (ages 0-3 and pregnant women) - this program runs all year
About You (parent/guardian)
Answer the following questions about the primary parent or guardian.
Name
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First Name
Last Name
Birth date
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Month
-
Day
Year
Date
Race
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Ethnicity
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Hispanic or Latino
not Hispanic or Latino
Gender
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Do you receive income?
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Yes
No
Which language do you normally speak at home?
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English skill level
Very well
Well
A little
None
Do you need an interpreter to communicate in English?
Yes
No
Written language preference (Spanish, English, or Somali)
Phone Number
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Please enter a valid phone number.
Can we send you text messages?
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Yes
No
Email
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example@example.com
Preferred method of communication
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Email
Text
Phone call
About your Head Start child
Full legal name If your child has a middle name, include it. If your child has more than one last name, please include them both. Their name here should appear exactly as it does on their birth certificate. If they are a Junior , a III, etc. please also include that information as well.
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First Name
Middle Name
Last Name
Suffix (if applicable)
Birth date
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-
Month
-
Day
Year
Date
Gender
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Race
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Ethnicity
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Hispanic or Latino
not Hispanic or Latino
What language(s) does your child speak at home?
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Does your child have a diagnosed disability or a serious medical condition?
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Yes
No
Has your child completed Early Childhood Screening?
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Yes
No
Does your child have an IEP or IFSP through the school district?
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Yes
No
Do you have concerns about your child's development?
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Yes
No
If you have concerns about your child's development, please explain:
Special Situations
Certain factors make a child automatically eligible for Head Start. Other factors give a child preference for enrollment. Please mark the boxes if any of these apply to your family.
We are living in a motel, hotel, or campground because we cannot afford housing
We are living in an emergency or transitional shelter
We are sharing housing with another person or family because we lost or cannot afford our own housing
We are living in a vehicle at this time (any kind of vehicle)
We consider ourselves homeless
Child is a foster child
Child is in custody of a non-parent family member
Income
Please check all sources of income for you or anyone else in your household in the past year
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Wages/Salary
Cash Assistance (TANF/MFIP)
SSI (Supplemental Security Income)
Social Security Income (SSDI, RSDI, SSA)
DWP (Divisionary Work Program)
Self Employment or Farm Income
Unemployment
Long or Short-Term Disability
SNAP/Food Support
WIC
No Income in the past year
Gifts
Other
About your family
Please count and list everyone who lives in your home at this time
How many people live in your home?
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Please list ALL people living in your house right now, other than the primary parent/guardian and Head Start child listed above.
Full Name
Date of birth
Relationship to the Head Start child
Does this person receive income? (yes/no)
Person #3
Person #4
Person #5
Person #6
Person #7
Person #8
If there are 2 adults living in the home, are you both the biological (or adopted) parents of the Head Start child?
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Yes
No
Not Applicable
If there are 2 adults living in the home, are you legally married?
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Yes
No
Not Applicable
Is anyone in the home pregnant?
Yes
No
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from Home Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information
Are you a staff member of an agency (Three Rivers, Social Services, Public Health, etc.) helping the applicant with this form? If so, please provide your name here.
How did you hear about us?
Document Uploads
We require documentation of your household income, your child's birthdate, and your child's IEP or IFSP, if applicable. You can upload the documents here, text pictures to 507-696-1970, email them to cklein@threeriverscap.org, or bring them to a Three Rivers office to be copied.
Income documents
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If you receive SNAP, Cash Assistance, or Supplemental Security Income, please a copy of your EBT card, MFIP statement, or SSI letter. If your child is a foster child, please provide the foster reimbursement or court order. If your family is experiencing homelessness, we will send a form for you to complete. If none of these apply, we will ask for your W2, 1040 Income Tax form, or a year of paystubs from the previous calendar year or last 12 months. We may follow up for more documentation.
Cancel
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Birthdate proof documents
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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. If you do not have anything, we may be able to verify your child's birthdate another way.
Cancel
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IEP/IFSP documentation
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Please upload any active IEPs/IFSPs, child support documents, or any other requested documentation here
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Data Privacy, Release of Information, Signature
Yes, I agree to the release of my information as outlined in the paragraph below. I understand my rights and responsibilities, and I certify that this information is true and accurate. I give permission for Three Rivers Head Start to: (1) 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 (2) 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 (3) 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. 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.
Signature
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Date
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Month
-
Day
Year
Date
Next Steps
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. We will follow up with you if we need more documentation to verify your family's eligibility for the program or to let you know if your child is accepted. Feel free to text or call 507-696-1970 or email cklein@threeriverscap.org with any questions about the application or next steps. Thank you!
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