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22-23 Referral to McKinney-Vento
This form is for LRSD staff to refer students/families for services through the McKinney-Vento Program.
Questions? Contact
Vicky Simpson, Liaison
Email:
Vicky.Simpson@lrsd.org
501 Sherman Street
Phone: (501) 447-2988
Fax: (501) 447-2982
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Name and Position of staff making referral
*
Your answer
School Site
*
Your answer
Students name
*
Your answer
Parent/Guardian name
*
Your answer
Parent phone
*
Your answer
Current address
*
Your answer
Siblings?
*
Yes
No
Names of siblings/schools
*
Your answer
Reason for this referral?
Your answer
Student's primary nighttime residence?
Shelter/transitional housing
Doubled up (temporarily staying with family and or friends)
Hotel/Motel resident
Unsheltered/vehicle/encampment/campground
Homeless unaccompanied youth (not in custody of parent/couch surfing with friends/family, or on the street)
Other:
Clear selection
Please indicate areas of urgency and concerns
School enrollment assistance
Transportation to and from school is needed
Student/family needs assistance accessing community services
Family needs certification of homelessness to complete housing apps and shelter stay
Other:
A copy of your responses will be emailed to the address you provided.
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