Student Housing Questionnaire

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Email *

Student's last name: *

Student's first name: *

Student's middle name: *

Student's gender: *

Male

Female

Non-Binary

Student's date of birth: *

YYYY

Student's grade: *

Home address - street/route with number: *

for example: 42 Husky Lane

Home address - apartment number (optional):

Home address - town/city: *

Home address - zip code: *

Phone number: *

This number is: *

Home (landline)

Cell

Residency

The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don't have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Where is the student currently living? Please check 1 box. *

in permanent housing (house or place you own or rent).

in a shelter.

With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as "doubled-up")

In a shelter.

in a hotel/motel.

in a car, park, bus or train, or campsite.

Other temporary living situation.

Required

If you checked the box for "Other temporary living situation," please describe.

Name of the person filling out this form: *

By typing your name below, you affirm that you are authorized to provide this information regarding the student and that all the information is accurate.

A copy of your responses will be emailed to the address you provided.

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