*
Required
Name of School
Student First Name
Student Middle Name
Student last Name
Sex
Male
Female
Date of Birth
(mm/dd/yyyy)
Age
The answers below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.
Where is the student currently living (Check one box.)
In a shelter
With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as ‘doubled-up’)
In a hotel/motel
In a car, park, bus, train or campsite
In permanent housing
Other temporary living situation (Please describe):
PRINT name of Parent, Guardian, or Student (for unaccompanied homeless youth)
Phone
*
required
Date
*
required
(mm/dd/yyyy)
Please provide address of temporary housing:
*
required