Student Housing Questionnaire

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The information provided below will help OYA determine what services you and/or your child or children may be able 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 personnel.

If you have any questions regarding this subject, please contact our Opportunity Youth Academy Assistant Principal Dr. Katherine Everett at (408) 573-3264 or send an email to keverett@sccoe.org. Additional information can be found at the California Department of Education Homeless Education Program website at https://www.cde.ca.gov/sp/hs/

Who is your teacher? *

Mrs. Raj Pawar (Sobrato)

Mrs. Cid Azevedo (South County)

Mrs. Tara Guerrero (MetroEd)

Mrs. Mary Bravo (ConXion)

Mrs. Annie Kretowicz (The Hub)

Mr. Mike Dempsey (The Hub)

Mr. Kevin Jacks (ConXion)

Mr. Louis Smith (Washington)

Mrs. Anne Le (Washington)

Ms. Riju Krishna (Snell)

Required

Student Last, First, Middle Initial *

Student date of birth. *

YYYY

Currently, what is you or your families living situation? *

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.

Living in a foster or group home setting.

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

Yes

I certify that the information provided above is correct and accurate. (type name) *

Current phone number.

Current living location or address. *

Please list all children living with you (please skip if none): Name, gender, birthdate, grade, school.

Your child or children 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; receive the same special programs and services, if needed, as provided to all other children, including free meals; and Title I protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families. If you have any questions about these rights, please contact the local homeless liaison, Joann Vaars at jvaars@sccoe.org or call (408) 573-6982. *

I understand my rights.

I would like more information about my rights.

Required

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