CORE Butte Housing Questionnaire

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California Department of Education (CDE) March 2020

The information provided below will help the school determine what services you and/or your child may be eligible to receive. This could include additional educational services through Title I, Part A and/or the federal McKinney-Vento Assistance Act. The information provided on this form will be kept confidential and only shared with appropriate school district and site staff.

Student Last Name *

Student First Name *

Student School ID#

If applicable.

Grade

Personalized Learning Teacher (PLT)

If applicable.

Presently, are you and/or your family living in any of the following situations? Check all that apply. *

Staying in a shelter (family shelter, domestic violence shelter, youth shelter) or Federal Emergency Management Agency (FEMA) trailer

Sharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing, or similar reason

Living in a car, park, campground, abandoned building, or other inadequate accommodations (i.e. lack of water, electricity, or heat)

Temporarily living in a motel or hotel due to loss of housing, economic hardship, natural disaster, or similar reason

Living in a single-home residence that is permanent (may be a rental)

I am a student under the age of 18 and living apart from parent(s) or guardian

Required

First date of current living situation

Please estimate if not known.

YYYY

The undersigned parent/guardian certifies that the information provided above is correct and accurate.

Parent/Guardian Name *

Date *

YYYY

Phone Number *

Street Address

City

Zipcode

Your child or children may have the right to:

Immediate enrollment in the school they last attended (school of origin) or the local school where you are currently staying, even if you do not have all the documents normally required at the time of enrollment.

Continue to attend their school of origin, if requested by you and it is in the best interest.

Receive transportation to and from their school of origin, the same special programs and services, if needed, as provided to all other children, including free meals and Title I.

Receive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families.

Please list all children (Name / ID# / Grade / PLT) currently living with you *

Please include ID & PLT if applicable.

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