MCC Student Residency Questionnaire

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This form is.intended to address the McKinney-Vento Act 42 U.S.C 11435, and must be completed for each student as required by law. The information you provide is confidential. Your child will not be discriminated against based on the information you provide.

Please complete the following questions regarding the student's housing in order to help determine if the student may be eligible to receive services. You may be contacted by our school district's Homeless Liaison if it is determined that the student meets the proper criteria for services.

Student Name: *

Gender: *

Male

Female

Date of Birth *

YYYY

Grade in School *

Little Rebels

Jr. K

Current Address: *

Parent/Guardian Phone Number: *

Please identify the student's current living arrangements: *

Doubled up: Living with another person or family due to loss of housing or economic hardship.

Shelter: Emergency or transitional shelter.

Awaiting Foster Care Placement

Hotel / Motel: Living in what is NOT an emergency or transitional shelter AND involves payment.

Other Temporary Living Situation: Campground, car, park, abandoned building or any other inadequate living space.

Unaccompanied Youth: Youth living with an adult who is NOT a parent or legal guardian OR a youth living alone without an adult.

Permanent Housing: Student is living in a fixed, regular, and adequate housing situation.

Parent / Guardian Name *

By entering your name here you are agreeing that the above information is true to the best of your knowledge.

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