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Children and Youth Transition Intake Form
The Children & Youth in Transition Program supports the continuity of education of students in transition including: students lacking a fixed, adequate, and/or regular nighttime residence (McKinney Vento definition) and students living in the Foster Care system.
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Email
*
Your email
Today's Date:
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MM
/
DD
/
YYYY
Who is completing the form? (Parent, Guardian, Resource Parent, School Counselor, Teacher...etc.)
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Your answer
Student name and ID:
(if unknown type 00000)
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Your answer
Age:
Your answer
Date of Birth:
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Your answer
School Site:
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Your answer
Parent/Guardian:
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Your answer
Contact Phone Number:
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Your answer
Email Address:
Your answer
Please identify your current living situation:
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Sharing housing with others due to loss of housing, economic hardship or similar reason, or doubled up with another family
Staying in a shelter
Unknown night- time residence
Living in a car, park, campground, public space, abandoned building, substandard housing or similar
Temporarily living in a motel or hotel due to loss of housing, economic hardship, or similar reason
In foster care and/ or group home
Unaccompanied (Student living with someone other than his/her legal guardian)
None of the above
Other:
Student Needs:
(Check all that apply)
Needs Free meal authorization
Birth Certificate is needed
Needs assistance accessing community resources
Needs assistance obtaining health services
Needs school supplies
Unable to pay school fees
Excessive absences
Immunizations are needed
Behavior indicates need for mental health counseling
Lacks academic record
Needs transportation to school
Needs personal toiletries
Needs tutoring
Needs clothing
Shirt Size:
(if in need of school clothes)
Your answer
Pants Size:
(if needed)
Your answer
Shoe Size
: (if needed)
Your answer
Do you have any other information you would like to share?
Your answer
Send me a copy of my responses.
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