Enrollment Information

Yog koj muaj lus nug los yog xav tau neeg pab teb daim ntawv no, hu rau - 715-235-9122 (Menomonie - Connie)
Si quere esta Informacion en espanol, favor de llamar - 715-234-5437 (Rice Lake - Yolanda) or 715-246-3232 (New Richmond - Onelia)
***Please submit a separate enrollment form for each child you would like to enroll

Please scroll to the bottom of this page to see the income guidelines

PreEnrollment Form:

***Child's First Name

Child's Last Name

Child's Date of Birth: (mm/dd/yr)

Parent(s)/Guardian(s) Name

Contact Phone Number

I am applying for:

My child has been or is currently enrolled in a preschool, child care, or other program.

Yes

Is there other information you would like us to consider?

Please select the Head Start Center that you think is closest to your residence: See a program map here

	Chippewa Falls			Colfax
	Cornell			Dallas (Barron 4K, Chetek, Cameron 4K, Almena 4K, Ridgeland 4K))
	Durand			Ellsworth
	Menomonie			New Richmond
	Polk County Early Learning Center (Frederic 4K, Luck 4K, Osceola 4K, and St. Croix Falls 4K			Rice Lake (Rice Lake 4K and Cameron 4K)
	Stanley - Boyd

10.

Where did you hear about the Head Start Program?

* Enter Your Email Address:

Type in the text that you see above:

The following figures are the 2012 HHS poverty guidelines that are scheduled to be published in the Federal Register on January 26, 2012.
(Additional information will be posted after the guidelines are published.)

2012 Poverty Guidelines for the
48 Contiguous States and the District of Columbia
Persons in family/household	Poverty guideline
1	$11,170
2	15,130
3	19,090
4	23,050
5	27,010
6	30,970
7	34,930
8	38,890
For families/households with more than 8 persons, add $3,960 for each additional person.

CESA #11 Head Start participates in the Child and Adult Care Food Program (CACFP). The primary goal of the CACFP is to improve the diet of children 12 years of age or younger.

In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.