​ ​Student​ ​Residency​ ​Questionnaire

Name​ ​of​ ​School:________________________________________________________

Name​ ​of​ ​Student:________________________________________________________

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​Last First Middle

This​ ​questionnaire​ ​is​ ​intended​ ​to​ ​address​ ​the​ ​McKinney-Vento​ ​Act​ ​42​ ​USC​ ​11435​ ​and​ ​help​ ​us​ ​to​ ​identify
homeless​ ​students.​ ​ ​Homeless​ ​students,​ ​as​ ​defined​ ​by​ ​the​ ​U.S.​ ​government,​ ​are​ ​entitled​ ​to​ ​special
services​ ​provided​ ​by​ ​the​ ​district.​ ​ ​The​ ​answers​ ​to​ ​this​ ​residency​ ​information​ ​help​ ​us​ ​to​ ​determine​ ​the
services​ ​this​ ​student​ ​may​ ​be​ ​eligible​ ​to​ ​receive.

Please​ ​check​ ​all​ ​that​ ​apply:

❏ Student​ ​is​ ​sharing​ ​a​ ​resident​ ​with​ ​one​ ​or​ ​more​ ​families​ ​because​ ​of​ ​economic​ ​hardship​ ​or​ ​similar
reason.
❏ Student​ ​is​ ​living​ ​in​ ​a​ ​motel​ ​or​ ​hotel.
❏ Student​ ​is​ ​living​ ​in​ ​a​ ​shelter​ ​(domestic​ ​violence,​ ​emergency,​ ​or​ ​transitional​ ​housing​ ​units).
❏ Students​ ​is​ ​living​ ​in​ ​a​ ​car,​ ​park,​ ​campground,​ ​or​ ​public​ ​place.
❏ Student​ ​is​ ​living​ ​in​ ​a​ ​place​ ​without​ ​adequate​ ​facilities​ ​(no​ ​heat,​ ​water​ ​or​ ​electricity,​ ​etc).
❏ Student​ ​is​ ​seeking​ ​enrollment​ ​without​ ​accompanying​ ​parent​ ​(not​ ​in​ ​foster​ ​care).

If​ ​none​ ​of​ ​the​ ​above​ ​apply,​ ​no​ ​additional​ ​information​ ​is​ ​required.​ ​ ​If​ ​you​ ​checked​ ​ANY​ ​of​ ​the​ ​above,​ ​please
continue:

Student​ ​Birth​ ​Date:________________________ Age:______ Grade:__________

Address:_____________________________________ Phone:__________________​ ​ ​Gender:_______

Name​ ​of​ ​parent​ ​or​ ​legal​ ​guardian:_________________________________________________________

Signature:_________________________________________________​ ​ ​Date______________________

Relation​ ​to​ ​student: Parent Guardian Other​ ​_________________