J

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

September 23-25, 2022
$200.00 - Classmate and guest
$300.00 - Classmates married within the class

Section A. Name /Names

Student

Gender

Female

Male

Prefer not to say

Other:

Clear selection

Date of Birth

YYYY

Grade

School

Carter-Parramore Academy

Chattahoochee Elementary School

Crossroad Academy Charter School

Gadsden Central Academy

Gadsden County High School

Gadsden Elementary Magnet School

George W. Munroe Elementary School

Greensboro Elementary School

Havana Magnet School

James A. Shanks Middle School

Stewart Street Elementary School

West Gadsden Middle School

Clear selection

Section B. Parent/Guardian Information

Name of Parent/Guardian

Current Street Address

City

Zip Code

Home Phone Number

Cell Phone Number

Email Address

Section C. Program Eligibility

Please Check All That Apply

1 - Family/Student In Transition: A family or student who lacks a fixed, regular and adequate night time residence due to circumstances of natural disaster or family hardship. This student is homeless but does not meet the definition of unaccompanied youth.

2 - Unaccompanied Youth in Transition: A child or youth not in the physical custody of a parent or guardian who also lacks a fixed, regular and adequate night-time residence due to circumstances of natural disasters or personal hardships.

3 - Migrant: Have you or your family moved within the last three years with the intent to find work in agriculture or fishing.

4 - Not Applicable: This student does not meet the definition of a homeless youth (or student for homeless services). If you checked statement, please skip to "Section E" and check Z then click on Submit at the bottom of the form.

Section D. Residential Status

If you, your child, or a child in your care has experienced any of the following descriptions during this school year, please enter a check mark for each that applies.

A - Living in an emergency or transitional shelter or FEMA trailer.

B - Sharing the housing of other persons (Grandparent, aunt, uncle, cousin, step parent, etc.) due to loss of housing, economic hardship or a similar reason.

D - Living in a car, park, temporary trailer park or campground, public space, abandoned building, substandard housing, bus or train station, public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings or similar setting due to lack of adequate alternative accommodations.

E - Living in a hotel or motel.

Section E. Cause of Temporary Residence

Please check the reason that most describes your condition

D - Man-made Disaster (Major)

E - Earthquake

F - Flooding

H - Hurricane

M - Mortgage Foreclosure (homeless family loses own home due to foreclosure)

N - Other homelessness causes (includes lack of affordable housing, long-term poverty, unemployment or underemployment, lack of affordable health care, mental illness, domestic violence, forced eviction, etc.)

P - Pandemic (Major)

S - Tropical Storm

T - Tornado

U - Unknown

W - Wildfire

Z - Non-Homelessness (No, student is not homeless and has not been homeless this school year.)

Clear selection

Section F. Only Unaccompanied Homeless Youth Must Complete This Section

An unaccompanied youth is any student not living in the physical custody of a parent or legal guardian.

If you are an unaccompanied homeless youth, what is the living status?

Living with an adult that is not a parent or legal guardian.

Living alone without an adult.

Clear selection

If living alone without an adult, how long have you been living alone?

If living with an adult that is not a parent or legal guardian, please provide the following information:

Caregiver Name:

Caregiver's relationship to student:

Caregiver's phone number:

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms