Student Residency Questionnaire

This questionnaire is intended to address the McKinney-Vento Act, in regards to children and youth in transitional living arrangements. Your answer will help the administration determine residency documents necessary for enrollment and additional services available to your family. This questionnaire will be kept separately from the student's permanent record and filed y the Homeless Education Liaison.

School Year: 2019-2020

Student's Name

Last Name *

First Name *

Middle Initial

Birth Date * +

Age *

Grade Level *

1. Presently, where is the student living? Please check one: *

In a shelter or temporary housing

With more than one family in a house or apartment

In a motel, car, or campsite

With Friends or family members (other than parent/guardian)

None of the above

Other Other

2. The student lives with: Please check one: *

3. Are you a student under the age of 18 living apart from your parents or guardians? *

Yes

No

4. Is the student living in shared housing? *

Yes

No

5. If you are living in shared housing, please check all of the reasons that apply: *

Electronic Signature of Parent/Guardian (use your mouse or finger for touch screens and trackpads) *

clear

Today's Date * +