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SPS Registration: McKinney-Vento Questionnaire Form
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Email
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McKinney-Vento Questionnaire Form
Student Name
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Student Date of Birth
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McKinney-Vento Questionnaire Form: The answers to the following questions can help determine the services this student may be eligible to receive under the McKinney-Vento Act 42 U.S.C. 11435. The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. The information you provide is confidential. If eligible, students are to be immediately enrolled in accordance with The McKinney-Vento Assistance Act. Do you/your student live in any of these following situations?
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In a motel
In a shelter, or transitional housing program
Moving from place to place/couch surfing
Sharing the housing of others due to a loss of housing, economic hardship, or similar reason
In a car, park, campsite, abandoned building, bus/train station or similar location
In a residence with inadequate facilities (no water, no heat, no electricity, etc.)
Not Applicable
The undersigned certifies that the information provided here is true and correct under penalty of perjury under the laws of the State of Washington: (please type first & last name of person completing this form)
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Address of current residence:
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Phone Number
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Student is:
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Living with a legal parent/guardian
Not living with a legal parent/guardian
Signature (please type first & last name)
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Date
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