Temporary agency fax # 612-235-6762

Program Forms

Program Forms
Program Forms

Training Library & Webinars
Training Library

Policies & Procedures 
Policies and Procedures

Website Links
Website Links

Early Head Start & Head Start Program Forms and Informational Handouts


NAME, ADDRESS, PHONE or EMAIL ADDRESS (changes to the HS participant or primary adult name, address, phone number, or email address)

NON-Foster Change of Custody (changes in the HS participants custody situation, not to include foster care changes)

HOUSEHOLD MEMBERS (changes in household member(s) moving in or out of the house)

FOSTER CARE (changes in the HS participant foster care situation)

ACCESS TO CHILD (changes to the emergency card or OFP information)

OTHER Information (changes to HS participant medical insurance, medical/dental home, family benefits (WIC, TANF, food stamps), or current adult employment, school, or education status )

Income Verification Form Income Verification Form

Playground "Fix It" Form

Request for Records - This form will be used by all staff to submit a request to the Head Start office to process a "Request for Participant's Records".

Staff - Submit An Individual Training Completed Form: Formerly titled "External Training Tracker". Use this form to submit training information for a training you have completed individually outside of trainings planned, organized, and held by Head Start.

Office - Submit a Planned Head Start Training: For OFFICE USE ONLY. Use this form to submit a training being planned and organized by the office for staff to participate in.

Program forms listed below are either fillable (F) or printable (P) as indicated at the end of each form name.
There are two category of forms:  Child/Family Forms & Staff Related Forms

Child and Family Program Forms
Behavior Tracking Tool (F/P)
Bus Evacuation Drill Report (F)
Bus Attendance and Tracking (MS Excel Document) (P)

Case Management (F)
Child Abuse and Neglect Report Form (F) - ST. LOUIS COUNTY Report Child Abuse LINK
Children's Dental Service (CDS) Consent Form (P)
CACFP - Breakfast Menu (F)
CACFP - CACFP Site Monitoring - Five Day Reconciliation Form (F)

CACFP - Child and Adult Care Food Program (CACFP) Enrollment Form (F)
CACFP - Classroom Child Food Restriction (F)
CACFP - Field Trip Food Record (F)
CACFP - Food Temperature Log (F)
CACFP - Milk Substitution (F)
CACFP - Snack Menu (F)
Child and Family Signature Tracking (P) 
Child Referral Form (CRF)
Daily Sign In/Out Form (P)
Disposition of Medication (P)

EHS Transition Form (F)
Field Trip and Event (F)
Foundation Fund Application (MS Word) (P & F)
Getting to Know Your Child and Family (P)
Immunization Exemption Form (MN Dept. of Health) (P)

Lesson Plan - Preschool (F)
Lesson Plan - Media Use Template (F)
Lesson Plan - Small Group Activity Template (F)
Lesson Plan - Distance Learning (F)
MARRS (MN Early Childhood Registration Form) (P)
Minneapolis Preschool Screening Instrument (For RESCREEN ONLY) (P)

Pathway I Scholarship Application (F)  ~  Pathway I Instructions Only

Pathway II Scholarship Application (F) ~  Pathway II Instructions Only

SEAM - Infant Family Profile SEAM (F)
SEAM - Toddler Family Profile SEAM (F)
SEAM - Preschool Family Profile SEAM (F)
Separation Report (P)
Sign In/Out - Non Parents Form (P)
Socialization Form (P)

Strengths & Difficulties Questionnaire (SDQ) (F)

Staff Forms:
Bloodborne Exposure Medical Exam Declination for Staff (Blood Borne Exposure Form) (P) 
Employee Health Exam Form (P)
Employee Hepatitis B Vaccination Form (Blood Borne Exposure Form) (F)
HUB & Family Needs Assessment Staff Worksheet (P)
Material Requisition Request Form (F) - Click here for the Head Start: Inventory Catalog (P)
Paid Time Off (PTO) Pay Out (P)
Post Exposure Medical Evaluation(Blood Borne Exposure Form) (P)
Staff Emergency Information (F)
Staff In Service Training Record (DHS-4679-ENG) (F)

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