Head Start Application

Child's Full Name
First Middle Last
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
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
Mailing Address (if different than home address)
Street Address Address Line 2 City State ZIP Code
County
Parent/Legal Guardian’s Full Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship to Child
Legal Guardian
- Yes
- No
Languages Spoken
Interpreter needed
- Yes
- No
Gender
- Male
- Female
Primary Phone Number
Secondary Phone Number
Text Messages?
- Yes
- No
Email Address
Parent/Legal Guardian’s Full Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship to Child
Legal Guardian
- Yes
- No
Languages Spoken
Interpreter needed
- Yes
- No
Gender
- Male
- Female
Primary Phone Number
Secondary 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
Is mom pregnant?
- Yes
- No
Due Date
Date Format: MM slash DD slash YYYY
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
2021 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	$12,880	7	$40,120
2	$17,420	8	$44,660
3	$21,960	9	$49,200
4	$26,500	10	$53,740
5	$31,040	11	$58,280
6	$35,580	12	$62,820

Proof of Income
Check all types of income and send proof for each item checked.
Do you have Wages
- 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 or DWP (Diversionary Work Program) assistance from the county
- Yes
- No
What to Send : current MFIP “Notice of Decision” from the county
Name of Person(s) Receiving Income - MFIP/TANF or DWP
Does your Child or other family member receive SSI (Supplemental Security Income)
- Yes
- No
What to Send : copy of the SSI letter
Name of Person(s) Receiving Income - SSI (Supplemental Security Income)
Social Security?
- Yes
- No
What to send : a statement or letter indicating the monthly amount received
Name of Person(s) Receiving Income - Social Security
Unemployment Compensation?
- Yes
- No
What to send : statement of amount received in the past 12 months
Name of Person(s) Receiving Income - Unemployment Compensation
Child Support?
- 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?
- 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?
- 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?
- Yes
- No
When did child begin foster care with you?
What to send : copy of foster care grant
Name of Person(s) Receiving Income - Foster Care
Relative Caregiver Grant is received for this child?
- Yes
- No
Date child came to live with you?
Date Format: MM slash DD slash YYYY
What to send : copy of grant award letter
Name of Person(s) Receiving Income - Relative Caregiver Grant
My family is “homeless”
- 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
- D. 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
Date Format: MM slash DD slash YYYY
Programs
Check one box below for the program that will work best for your family and this child.

EARLY HEAD START (2021-2022) Children who were born on/after 9/2/18 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-5:30pm	Child must be 6 weeks of age 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. Parent Transport both ways 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 (2021-2022)
Children who were born on/after 9/2/18 and pregnant women
- Early Head Start Child Care Center
- Early Head Start Home Based

HEAD START (2021-2022) Children whose birthdate falls between 9/2/16 and 9/1/18

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 or attend school a minimum of 30 hours per week. Child must attend 35 hours of HS Childcare rates $15/day Year Round Monday - Friday
St. Cloud Technical College 1701 9th Ave N, St. Cloud	8:00am - 3:00pm	Childcare available through Campus Playhouse August through June Monday-Thursday
Eastside Locations 1250 Johnson Rd, St. Cloud 358 Hwy 10 So, St. Cloud	7 Hour Class 8:00am - 3:00pm 7 Hour Class 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	7 Hour Class 8:00am - 3:00pm	August through June Monday-Thursday
Athlos Academy Location 3701 33rd St S, St. Cloud	8:30am - 3:30pm	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 (2021-2022)
Children whose birthdate falls between 9/2/16 and 9/1/18
- Head Start Child Care Center
- St. Cloud Technical College
- Eastside Locations
- Roosevelt Boys & Girls Club Location
- Southside Boys & Girls Club Location
- Athlos Academy Location
- Big Lake Location
- Head Start Home Based
Eastside Times
- 7 Hour Class 8:00am - 3:00pm
- 7 Hour Class 8:45am – 3:45pm
Southside Boys & Girls Club Times
- 7 Hour Class 8:00am - 3:00pm
**** For the 2021-2022 program year, transportation is no longer available ****
How did you hear about Reach-Up Head Start?
Additional Files and Forms such as proof of income, current immunizations and well child checkup
Please zip / compress all other forms or files you need to submit then upload your zip file here containing all files.

Full Name	Relationship to the Child	Date of Birth	Gender

2021 Federal Poverty Guidelines

Proof of Income

Programs