HOMELESS STUDENT IDENTIFICATION
Scott County School District 2 CONFIDENTIAL STUDENT RECORD
Name of SCHOOL STAFF completing this form
*
First Name
Last Name
Email address of SCHOOL STAFF completing this form
*
Scott 2 email address required
Phone number of SCHOOL STAFF completing this form
*
-
Area Code
Phone Number
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Student Living Status
Select the appropriate response in each category – Current Living Situation and Living Arrangements for Student Information System (SIS) Identification
Unaccompanied Homeless Youth
*
Yes
No
Current Living Situation
*
In a shelter
At a train or bus station, park or in a car
Doubled up with relatives or others due to lack of housing
In an abandoned apartment or building
Disaster victim
In a motel/hotel, campground, or other similar situation due to lack of alternative, adequate housing
Other
Living arrangements for SIS identification:
*
In a shelter
In a hotel/motel
Doubled up
Unsheltered (on the street, car, park, campground, abandoned building)
Notes/explanation of current living situation:
Does the student have access to reliable Wifi internet access where they are currently living?
*
YES
NO
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Student/Family Information
*
Student Name
Date of Birth
Grade
School
Special Ed.
Migrant
English Learner
Received Title IA Services
1.
2.
3.
4.
Name of parent(s)/legal guardian(s):
*
Name & relationship of person(s) with whom student or family is doubled up:
Name of educational guardian(s) (requires documentation):
Main contact phone number
-
Area Code
Phone Number
E-mail, if available:
example@example.com
*
Current Address
Move Date
Former Address
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District Information
School District of Origin:
*
School District of Residence
*
School District where child(ren) attend/are served:
*
Name of transportation billing staff contacted:
Name of Homeless Liaison contacted:
Date of contact:
/
Month
/
Day
Year
Date
Notes:
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Transportation
Transportation provided?
*
Yes
No
Type of transportation:
School bus (including additional or extended routes)
Taxi
City bus/public transportation
Contracted transportation service
Gas reimbursement
Other
Include any notes below regarding mileage calculation; or, shared transportation costs with another district (District of origin and district of residence will share transportation costs evenly (50/50), if no other agreement is in place).
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Resources and Services
Must be reviewed with parent/guardian/unaccompanied homeless youth in a manner and form that is understandable, including, if necessary and to the extent feasible, in the native language
McKinney-Vento rights reviewed (all required)
*
Immediate enrollment
Rights to attend district of origin/residence
Transportation
Free school meals/fees waived
Student information shared with the school district sharing transportation costs
Yes (if applicable)
School and district staff confidentially received student information
*
Food service
Registration/enrollment
Transportation department
Building social worker or counselor
Building principal
Community resources available and information shared
*
Food and clothing
Affordable permanent housing
Emergency shelter
Mental health services
Employment
Domestic abuse resources
Medical, dental, and other health services
Seasonal/holiday
Current order of protection or no contact order
*
NO
YES
Date & time shared with parent/guardian/unaccompanied homeless youth
*
/
Month
/
Day
Year
Date
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Minutes
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PM
AM/PM Option
Submit
Should be Empty: