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ECYEH Program 2023-2024 - Service Request Form
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Email
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Your email
** This form is to be completed by school district staff**
Please put name of staff member requesting clothing.
This form is not to be shared with anyone outside of the school district.
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Your answer
Is the school closed at any point over the next 10 days due to vacation days, in-service etc., not including weekends? (for gas cards only - put N/A if not requesting a gas card)
If yes, what are those dates?
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Your answer
What is the last day of school for the student/school district? (for gas cards only - put N/A if not requesting a gas card)
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Your answer
Date Requested
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MM
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DD
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YYYY
Best contact number of staff member making the request
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Your answer
Requester's Full Address - person who is completing the form (please include zip code)
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Your answer
Student's Name
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Your answer
Student's Date of Birth
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MM
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DD
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YYYY
School District
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Your answer
School Building Name
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Your answer
Grade
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Your answer
Gender
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Male
Female
Reason for Homelessness
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Abandonment
Act of Nature/Natural Disaster
Death of Parent/Guardian
Domestic Violence
Eviction
Fire
Hospitalization of Parent/Guardian
Incarceration of Parent/Guardian
Left Home
Military
Parental Job Loss/Loss of Income
Parental Divorce/Separation
Separated from Family
Other Poverty Related Situation
Unknown
Other
Current Nighttime Residence Status
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Doubled Up
Hotel/Motel
Shelter/Transitional Housing
Unsheltered
Items Requested
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Uniforms
Clothing - must be clothing to meet school dress code requirements
Gas Card - available to students/families while transportation is being set up
Bus Pass - Day Pass
Bus Pass - Monthly (please contact Sara Salopek to discuss)
Required
Quantity of bus passes needed if applicable. (Our office may reach out and see if a monthly bus pass may work better depending on the amount of bus passes needed.)
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Your answer
If a Gas Card is not being requested, please put N/A for the questions below.
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Your answer
If requesting a Gas Card, please provide the FULL address where the student is currently staying or doubled up. The miles from where the student is staying, the school, and then back is calculated to get the correct mileage reimbursement. The mileage reimbursement is based on the Federal Mileage reimbursement, which is currently 65.5 per mile, covering transportation for two weeks.
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Your answer
**Clothing and Uniform requests, please enter the size information and check the appropriate box(es) for the type of person. (If an item is not being requested, please check not applicable for the items below)
Your answer
Shirt Size
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Your answer
Question
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Child
Adult
Not Applicable
Pant Size
For adult men sizes -
Waist and Length are needed for jeans and dress pants (ex. 32x30)
For adult women pant sizes -
Juniors are odd sizes 1,5,9,13 etc.
Misses/Women sizes are even: 2, 4, 6, 8, 10, etc.
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Your answer
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Child
Adult
Not Applicable
Shoe Size
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Your answer
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Child
Adult
Not Applicable
Specific clothing requirements (please include uniform colors for shirts and pants if applicable)
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Your answer
A copy of your responses will be emailed to the address you provided.
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