Head Start Application – Reach-Up Head Start

Child's Full Name

First Middle Last

Date of Birth

Gender

Male
Female
Non-binary

Child’s Primary Language

Child 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 needed

Child’s Home Address

Street Address Address Line 2 City State ZIP Code

County

Primary Parent/Legal Guardian’s Full Name

First Last

Date of Birth

Relationship to Child

Mother
Father

Languages Spoken

Interpreter needed

Yes
No

Gender

Male
Female
Non-binary

Is this person the child's Legal Guardian?

Yes
No

Race

Hispanic/Latino

Yes
No

Phone Number

Text Messages?

Yes
No

Email Address

Secondary Parent/Legal Guardian’s Full Name

First Last

Date of Birth

Secondary Parent/Legal Guardian's Address (if different from Child's)

Street Address Address Line 2 City State Zip Code

County

Relationship to Child

Legal Guardian

Mother
Father

Languages Spoken

Interpreter needed

Yes
No

Gender

Male
Female
Non-binary

Is this person the child's Legal Guardian?

Yes
No

Race

Hispanic/Latino

Yes
No

Phone Number

Text Messages?

Yes
No

Email Address

Total Number of Family Members

List 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.

Full Name	Relationship to the Child	Date of Birth	Gender (M/F/N)

Is mom pregnant?

Yes
No

Due Date

Is the child on an IEP or IFSP?

send a copy of the IEP or IFSP with this application

Yes
No

please list contact information

Is the child on any emergency medication such as an Epi-Pen, rescue inhaler or seizure medications?

Yes
No

If yes, list the medication and physician who prescribed it?

Does this child have a food allergy?

Yes
No

list food allergy, the reaction, and any medication

2023 Federal Poverty Guidelines

A 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.

Size of Family	Income 100%	Size of Family	Income 100%
1	$14,580	7	$45,420
2	$19,720	8	$50,560
3	$24,860	9	$55,700
4	$30,000	10	$60,840
5	$35,140	11	$65,980
6	$40,280	12	$71,120

Proof of Income

Check 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

2022 W-2's or 2022 tax forms, or pay stubs for past 12 months.

Yes
No

What to Send : pay stubs for past 12 months, 2020 W-2’s or 2020 1040 Form

Name of Person(s) Receiving Income - Wages

Does your family receive MFIP/TANF, DWP (Diversionary Work Program) or SNAP assistance from the county

Current MFIP/DWP or SNAP Notice of Decision letter from the county.

Yes
No

What to Send : current MFIP, DWP or SNAP “Notice of Decision” from the county

Name of Person(s) Receiving Income - MFIP/TANF, DWP or SNAP

Does your Child or other family member receive SSI (Supplemental Security Income)

SSI statement or award letter indicating monthly payment amount.

Yes
No

What to Send : copy of the SSI letter

Name of Person(s) Receiving Income - SSI (Supplemental Security Income)

Social Security?

Social Security statement or award letter indicating monthly payment amount.

Yes
No

What to send : a statement or letter indicating the monthly amount received

Name of Person(s) Receiving Income - Social Security

Unemployment Compensation?

MN UE statement showing payments received in last 12 months.

Yes
No

What to send : statement of amount received in the past 12 months

Name of Person(s) Receiving Income - Unemployment Compensation

Child Support?

Child support award letter, online child support account printout for past 12 months or signed letter of child support payments.

Yes
No

What to send : total amount received in past 12 months; $__________

total amount received in past 12 months

Name of Person(s) Receiving Income - Child Support

College Grants and/or scholarships?

Award letter with grant or scholarship amounts listed.

Yes
No

What to send : copy of award letter with grant or scholarship amount

Name of Person(s) Receiving Income - College Grants and/or scholarships

No Income in the past 12 months?

Contact main office for Declaration of Income form.

Yes
No

What to send : Declaration of No Income will need to be filled out

Name of Person(s) Receiving Income - No Income

Is 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 Income

My family is “homeless”

Contact main office for Homeless Verification form.

Yes
No

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.

What to send : A Homeless Verification Form will need to be filled out.

Signature

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

Programs

Check 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 (2023-2024) Children who were born on/after 9/2/20 and pregnant women

Program Name & Location	Time	Age	Additional Information
Early Head Start Child Care Center Eastside 1250 Johnson Rd, St. Cloud	Early Head Start Time: 8:00am – 3:00 pm Child Care hours: 7:30am-8:00am & 3:00pm-5:00pm	Child must be 6 weeks old and can attend until their 3rd birthday	Parent must work or attend school a minimum of 30 hours per week. Child must attend 35 hours of EHS. Childcare rates are $18/day. Year Round Monday-Friday
Early Head Start Home Based Serves Stearns, Benton & Sherburne counties	Year Round	Pregnant women and children birth to 3 years old	Weekly 90 minute home visits Parent/Child Activity days 2x per month

EARLY HEAD START (2023-2024)

Children who were born on/after 9/2/20 and pregnant women

Early Head Start Child Care Center
Early Head Start Home Based

HEAD START (2023-2024) Children whose birthdate falls between 9/2/18 and 9/1/20

Program Name & Location	Time	Additional Information
Head Start Child Care Center Eastside 1250 Johnson Rd, St. Cloud	Head Start Time: 8:00am – 3:00pm Child Care hours: 7:30am - 8:00am & 3:00pm - 5:00pm	Parent must work and/or attend school a minimum of 30 hours per week. Parent must pay the required child care rate of $15/day Year Round Monday - Friday
Eastside Locations 1250 Johnson Rd, St. Cloud 358 Hwy 10 So, St. Cloud	8:00am - 3:00pm 8:45am – 3:45pm	August through June Monday-Thursday
Roosevelt Boys & Girls Club Location 345 30th Ave N, St. Cloud	8:00am – 3:00pm	August through June Monday-Thursday
Southside Boys & Girls Club Location 1205 6th Ave S, St. Cloud	8:00am - 3:00pm	August through June Monday-Thursday
Big Lake Location 17901 205th Ave, Big Lake	8:00am – 3:00pm	August through June Monday-Thursday
Head Start Home Based Serves Stearns, Benton & Sherburne counties	Year Round	Weekly 90 minute home visits Parent/Child Activity days 2x per month

HEAD START (2023-2024)

Children whose birthdate falls between 9/2/18 and 9/1/20

Head Start Child Care Center
Eastside Locations
Roosevelt Boys & Girls Club Location
Southside Boys & Girls Club Location
Big Lake Location
Head Start Home Based

Eastside Times

8:00am - 3:00pm
8:45am – 3:45pm

Hidden

Southside Boys & Girls Club Times

8:00am - 3:00pm

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 checkup

If you have more than one file or form please use the additional File/Form buttons below.

Max. file size: 20 MB.

File/Form 2

Max. file size: 20 MB.

File/Form 3

Max. file size: 20 MB.

File/Form 4

Max. file size: 20 MB.