Bartlesville School District

Residency Form 2011-2012

This form is intended to address the McKinney-Vento Act. Your answers will help determine
residency for enrollment and ensure that certain needs will be met for this student.

Student: ______________________________________________________
First Name Last Name MI

School: ________________________ Grade: _______ ❑ Male ❑ Female

Presently, where is the student living? Check one box.

Section A Section B

Temporarily living with other family members Choices in Section A do NOT apply.
(grandparents, aunts, uncles, cousins, etc.) or
friends due to loss of job, loss of housing, etc.
In a shelter
In a motel, hotel, car, or campsite
In a temporary foster care home awaiting
permanent placement
Alone without parental support (an independent
living student may also live with friends or other
family members)

***IF YOU MARKED A BOX IN SECTION A, PLEASE COMPLETE THE FORM BELOW***

Student ID#: _________________ Date of Birth: _________________

(Completed by School Staff)

Parent/Guardian: ______________________________________ Date: ______________

Present Address: _________________________________________________________

_________________________________ Phone: __________________

Last school attended: _________________________ City: _______________ State: ______

Please return this completed form to your school with your enrollment papers.

School Staff: Please send a copy of this form to Office 107; McKinley Building or fax to 336-0821.