Programs Application Child's Name First Middle Last Date of Birth MM slash DD slash YYYY Gender Male Female Non-binary Child's Primary LanguageChild Speaks English Very well Well Not well Not at all Child Lives with Mother and Father (Same Household) Mother (Separate Households) Father (Separate Households) Foster Family Relative/Other Please include legal documentation from the court, Social Worker, or other if neededChild's Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyBentonSherburneStearnsPrimary Parent/Legal Guardian’s Full Name First Last Date of Birth MM slash DD slash YYYY Relationship to Child Mother Father Other Languages SpokenInterpreter needed? Yes No Gender Male Female Non-binary Is this person the child's Legal Guardian? Yes No RaceHispanic/Latino Yes No PhoneText messages? Yes No Email Secondary Parent/Legal Guardian’s Full Name First Last Date of Birth MM slash DD slash YYYY Secondary Parent/Legal Guardian's Address (if different from Child's) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country CountyBentonSherburneStearnsRelationship to Child Mother Father Other Languages SpokenInterpreter needed? Yes No Gender Male Female Non-binary Is this person the child's Legal Guardian? Yes No RaceHispanic/Latino Yes No PhoneText messages? Yes No Email Total Number of Family MembersFull NameRelationship to the ChildDate of BirthGender (M/F/N) Add RemoveList all the other family members below who are living in the home and must be financially supported by the parent/guardian and related by blood, marriage or adoption. Is Mom pregnant? Yes No Due Date MM slash DD slash YYYY Is the child on an IEP or IFSP? Yes No Send a copy of the IEP or IFSP with this applicationList contact informationIs the child on any emergency medication such as an Epi-Pen, rescue inhaler or seizure medications? Yes No List food allergy, the reaction, and any medicationDoes this child have a food allergy? Yes No List the medication and physician who prescribed it?2024 Federal Poverty GuidelinesA family is eligible if the total income for the past year is at or below the Federal Poverty Guidelines. Family size includes family members who live with the child and are related by blood, marriage or adoption. Proof of IncomeCheck all types of income and send proof for each item checked. Proof of income will be collected from anyone financially supporting the child who is related by blood, marriage or adoption. **ALL INCOME DOCUMENTS MUST BE RECEIVED TO COMPLETE YOUR APPLICATION.**Do you have Wages? Yes No 2023 W-2's or 2023 tax forms, or pay stubs for past 12 months. If yes, send pay stubs for past 12 months, 2023 W-2’s or 2023 1040 FormName of Person(s) Receiving Income - WagesDoes your family receive MFIP/TANF, DWP (Diversionary Work Program) or SNAP assistance from the county Yes No Current MFIP/DWP or SNAP Notice of Decision letter from the county. If yes, send current MFIP, DWP or SNAP “Notice of Decision” from the countyName of Person(s) Receiving Income - MFIP/TANF, DWP or SNAPDoes your Child or other family member receive SSI (Supplemental Security Income) Yes No SSI statement or award letter indicating monthly payment amount. If yes, send copy of the SSI letterName of Person(s) Receiving Income - SSI (Supplemental Security Income)Social Security? Yes No Social Security statement or award letter indicating monthly payment amount. If yes, send a statement or letter indicating the monthly amount receivedName of Person(s) Receiving Income - Social SecurityUnemployment Compensation? Yes No MN UE statement showing payments received in last 12 months. If yes, send statement of amount received in the past 12 monthsName of Person(s) Receiving Income - Unemployment CompensationChild Support? Yes No Child support award letter, online child support account printout for past 12 months or signed letter of child support payments. If yes, send total amount received in past 12 monthsTotal amount received in past 12 monthsName of Person(s) Receiving Income - Child SupportNo Income in the past 12 months? Yes No Contact main office for Declaration of Income form.Name of Person(s) Receiving Income - No IncomeCollege Grants and/or scholarships? Yes No Award letter with grant or scholarship amounts listed. If yes, send copy of award letter with grant or scholarship amountName of Person(s) Receiving Income - College Grants and/or scholarshipsIs this child in foster care or relative care? Yes No What County?Attach court order or letter from county social worker.Name of Person(s) Receiving IncomeMy family is “homeless” Yes No Contact main office for Homeless Verification form.Choose the option that best describes your housing/home Temporarily sharing housing of another family due to loss of housing, economic hardship or similar reason Staying in an emergency or transitional shelter Living in a motel, hotel or campground because I cannot find or afford housing Living in a vehicle, an abandoned building or substandard housing without running water or electricity, or in a park, bus or train station. Signature(Required)I understand that all information provided to Reach-Up Inc. regarding my family is stored on an electronic database. It may be shared with other services used by Reach-Up Inc., such as the MN State Immunization Registry. By signing this form, I affirm that I believe these facts are true and accurate. I understand that I am asked to prove my statements. I understand that I may be prosecuted for fraud and perjury if I knowingly give false information.Date MM slash DD slash YYYY ProgramsCheck one box below for the program that will work best for your family and this child. **Parents are responsible for drop off and pick up of children for all locations.** Early Head Start (2024-2025) Children who were born on/after 9/2/21 and pregnant women Early Head Start (2024-2025) Early Head Start Child Care Center Early Head Start Home Based Children who were born on/after 9/2/21 and pregnant women Head Start (2024-2025) Children whose birthdate falls between 9/2/19 and 9/1/21 Head Start (2024-2025) Head Start Child Care Center Eastside Locations Roosevelt Boys & Girls Club Location Southside Boys & Girls Club Location Big Lake Location Head Start Home Based Children whose birthdate falls between 9/2/19 and 9/1/21. Program locations and times are subject to change. **NO transportation is provided.**How did you hear about Reach-Up Head Start?Additional Files and Forms such as proof of income, current immunizations and well child checkupIf you have more than one file or form please use the additional File/Form buttons below.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.CAPTCHA
