McKinney-Vento Program Intake Form

Student First & Last Name *

Grade Level *

Student ID

Enrolling School *

School of Origin *

School student was attending when they were last permanently housed.

Current Street Address *

City, State, and Zip *

Parent/Guardian Name

If student is unaccompanied, this can be left blank.

Parent/Guardian/UY Email

Parent/Guardian/UY Phone Number *

Sibling #1- List first & last name

Only include siblings who share the current living situation

Sibling #1- school name

Sibling #2- List first & last name

Only include siblings who share the current living situation

Sibling #2- school name

Sibling #3- List first & last name

Additional Siblings can be included in comments below.

Sibling #3- school name

For Head Start referral: list any additional siblings ages 0-5- first & last name with ages

Please explain how housing was lost (i.e. eviction, domestic violence, fire, etc.)

If you require this address to be confidential due to domestic violence or other reason, please note that here.

Name of person completing the form *

Additional Notes

Please include any additional information that may help us make this determination. If the student is in need of clothing or shoes, please include the sizes here.

Contact Information

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