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Student/Family Residence Questionnaire

Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Title X, the federal McKinney-Vento Homeless Assistance Act. Eligibility can be determined by completing the questionnaire below.

Your children have the right to:

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Parent/Guardian First Name: *

Parent/Guardian Last Name: *

Parent/Guardian Phone Number: *

Parent/Guardian Email Address:

Current Street Address:

City:

State:

ZIP code:

Presently, are you and/or your family living in any of the following situations? *

Check all that apply

Staying in a shelter (family shelter, domestic violence shelter, youth shelter)

Living in a car, park, campground, abandoned building, or other inadequate accommodation

Temporarily living in a motel or hotel due to loss of housing, economic hardship or similar reason

Living alone as a minor student(s) without a parent or legal guardian (unaccompanied youth)

None of the above

If you answered "None of the above" to the previous question, you do not need to complete or submit this form.

Please list all children currently living with you, including those not old enough for school.

Child 1

Child 1 First Name: *

Child 1 Middle Name: *

Child 1 Last Name: *

Child 1 Gender: *

Child 1 Date of Birth: *

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Child 1 Current Grade: *

Child 1 School: *

Would you like to add a second child? *

Yes

No

Child 2

Child 2 First Name: *

Child 2 Middle Name: *

Child 2 Last Name: *

Child 2 Date of Birth: *

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Child 2 Gender: *

Child 2 Current Grade: *

Child 2 School: *

Would you like to add a third child? *

Yes

No

Child 3

Child 3 First Name: *

Child 3 Middle Name: *

Child 3 Last Name: *

Child 3 Date of Birth: *

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Child 3 Gender: *

Child 3 Current Grade: *

Child 3 School: *

Would you like to add a fourth child? *

Yes

No

Child 4

Child 4 First Name: *

Child 4 Middle Name: *

Child 4 Last Name: *

Child 4 Date of Birth: *

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Child 4 Gender: *

Child 4 Current Grade: *

Child 4 School: *

Would you like to add a fifth child? *

Yes

No

Child 5

Child 5 First Name: *

Child 5 Middle Name: *

Child 5 Last Name: *

Child 5 Date of Birth: *

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Child 5 Gender: *

Child 5 Current Grade: *

Child 5 School: *

The undersigned parent/guardian certifies that the information provided above is accurate.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Guardian: *

Date:

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