Minnesota Head Start and Public Preschool Referral

Minnesota Head Start and Public Preschool Referrals is a way parents and other primary caregivers can let local Head Start and school district preschool programs know that you are interested in those programs for your child. It does not guarantee a space for your child in either Head Start or the school district, and is not an application. If you complete this form, staff from your local Head Start or school district will contact you to hear more about your needs and see if they are a good fit.

Additionally, if you are concerned about your child's development, please complete the referral form through the Help Me Grow website. The referral form will be sent to your local school district who will follow up with you to better understand your concerns and discuss any next steps.

Families are welcome to complete either or both the Head Start and Public Preschool Referral and Help Me Grow Referral forms, depending on your needs and concerns.

Finally, if you are interested in fee-based licensed center-based or family-based child care, or want to find your local Head Start or school district public preschool program to contact them directly, please go to the Parent Aware website to search by your address for the programs closest to you.

If you're not sure which type of care and education you're interested in, Parent Aware offers information on the different options that may help you learn more.

Thanks for completing this form!

Do you have worries about your child's development? *

    CHILD INFORMATION

    Each child must be referred individually. You will be given the option to 'Refer another Child' when you complete this referral. Starred (*) fields are required.

    Child Information

    Date of Birth
    (ages 0-4 years)
    Interpreter Needed

    Child Resides With

    Contact 1

    Relationship to Child*
    Is it ok to text these numbers?
    Is it ok for us to email you?

    Contact 2

    Relationship to Child
    Is it ok to text these numbers?
    Is it ok for us to email you?

    Physical address where child resides

    If the Family/Caregiver has no phone, please provide an alternative contact person

    The information contained in this form will be securely submitted electronically to the local Head Start agency and may be forwarded to the school district where the child lives. The parent or guardian should expect to hear from the Head Start agency or school district within the next seven to 10 days to discuss the request. If the request is being made during the summer months, the parent or guardian may not hear from the school district until school is back in session in the fall.

    Tennessen Warning from the Minnesota Department of Education for Accessing Coordinated Child Intake

    This notice applies to all information collected for the Coordinated Child Intake program. It explains what information we will collect and why we are collecting it.

    What Information are we requesting?

    The Minnesota Department of Education (MDE) requests all information on the Coordinated Child Intake form, some of which is considered private data under Minnesota law.

    Why do we ask you for this Information?

    Information on this form is required to seek information for free and low-cost preschool services. MDE will use the information collected here, and any additional, related information, to connect your family to preschool services.

    Am I required to provide this data?

    There is no legal obligation for you to provide the data requested; however, without it, MDE cannot determine your child's eligibility, and your child may not receive services.

    Who else may see this information?

    As described elsewhere in the application, with your required informed consent, MDE will share your information with the area Head Start agency, school district or childcare program, and the Minnesota Department of Education. All of these entities, including a program evaluator, are bound by Minnesota's data practices and privacy laws and will not share your private data except as described here. The evaluator must not share your data with anyone except MDE.

    MDE may also give the data you have provided to the Legislative Auditor, the Minnesota Department of Human Services, and/or other agencies with the legal authority to access the information, or anyone authorized by a court order.

    How else may this information be used?

    MDE may use or release this information only as stated in this notice, unless you give MDE your written permission to release the information for another purpose, or to another individual or entity. The information may be used for another purpose if the U.S. Congress or the Minnesota Legislature passes a law allowing or requiring other uses.

    How long will my data be kept?

    Your data will be kept for a minimum of seven years.