SCS Residency Form- SCMS

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This form is intended to address the requirements of the McKinney-Vento Act (Title IX, Part A of the Every Student Succeeds Act). The questions below will assist in determining if the student meets the eligibility criteria for services provided under the McKinney-Vento Act.

Email Addresses

Student Name *

Names are organized by Grade Level - Name (Homeroom Teacher)

Gender *

Male

Female

Date of Birth *

YYYY

WHERE DOES THE STUDENT STAY AT NIGHT? *

In a shelter

In a hotel/motel

In a car

At a campsite

Alone

In another location that is not appropriate for people (e.g., an abandoned building)

Temporarily with more than one family in a house, mobile home, or apartment

(doubled-up, not by choice. Would not have a place to stay if not doubled-up.)

Other (in an arrange that is not fixed, regular, and adequate and is not described by the other choices)

Choices above do not apply

Parent/Guardian Name(s) *

Address *

City *

Zip Code *

Home Phone (or the number of a contact person that can reach you) *

Please Type Your Name Below

I am verifying that the above student(s) listed have not had a fixed, regular, or adequate nighttime residence.

Today's Date *

YYYY

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