PSD Residency Form

2020-2021 Residency Form
Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act./Uaak ko am ijin ilal renaj kalikar elañe rijikul eo ej maroñ dreloñe im bõk jibañ ko im rej bed iumin McKinney-Vento Act.

List all children in your family birth through age 21./Likit etan aolep ajiri ro ilo nukun eo im rej drettan in 21 iiõ laỊọk.
Name of Child 1/Etan ajiri eo 1
Child 1 School/Jikul eo an
Child 1 Age/Yiỡ
Child 1 Grade/Kilaaj jete
Child 1 Date of Birth/Raan in lotak

Month Day Year
Date
Name of Child 2/Etan ajiri eo 2
Child 2 School/Jikul eo an
Child 2 Age/Yiỡ
Child 2 Grade/Kilaaj jete
Child 2 Date of Birth/Raan in lotak

Month Day Year
Date
Name of Child 3/Etan ajiri eo 3
Child 3 School/Jikul eo an
Child 3 Age/Yiỡ
Child 3 Grade/Kilaaj jete
Child 3 Date of Birth/Raan in lotak

Month Day Year
Date
Name of Child 4/Etan ajiri eo 4
Child 4 School/Jikul eo an
Child 4 Age/Yiỡ
Child 4 Grade/Kilaaj jete
Child 4 Date of Birth/Raan in lotak

Month Day Year
Date
Parent/Guardian Name/Etan Mama/Baba ak ro rej lale ajiri eo
Parent/Guardian Address/Jikin Jokwe
Parent/Guardian City/Taun
Parent/Guardian Zip Code
Parent/Guardian Phone Number/Numba
Is this address Temporary or Permanent (Circle One)/Jikin jokwe in ej ñan Jidik Wōt Ien ke ňan Indreo? (doulul i juõn iaer)

Temporary/Jidik Wōt Ien Permanent/Indreo
Please choose which of the following situations the student currently resides in (you can choose more than one):/Jouj im kalikar wawein kab ia eo rijikul eo ej jokwe ie (Komaroñ kelet elõñlok jen juõn):

House or apartment with parent or guardian/Em ak abatmen ko Motel, car, or campsite/Motel, wa ko, ak camp ko Shelter or other temporary housing/Shelter ko With friends or family members (other than or in addition to parent/guardian)/Mwõn armej ro mõtan bamle eo (ijelokin moko mwõn jineer/jemeir ak ro rej lale er)
If you are living in shared housing, please check all of the following reasons that apply:/Elañe kwõj jokwe ilo kabijuknen eo elõñlok jen juõn ak ruo bamle ilowan, kalikar un eo:

Loss of housing/Luuji kabijuknen eo an Economic situation/Jabwe jaan Temporarily waiting for house or apartment/Kõtar an wõr bellok ilo bar juõn em ak abatmen Provide care for a family member/Bed im jibañ bamle eo juõn ilo kabijuknen eo Living with boyfriend/girlfriend/Jokwe ipan armej eo rejtan/mõttan (ledik eo/ladik eo jeran) Loss of employment/Ejako an jerbal Parent/Guardian is deployed/Jinen im jemen rerool ñan aelõñ eo aer
Are you a student under the age of 18 and living apart from your parents or guardians?/Kwe ke rijikul eo im ediklok jen 18 an iiõ im ejab jokwe ipan jinen/jemen ak ro rej lale?

Yes/Aet No/Jaab
Housing and Educational Rights/Maroñ Ko An Juõn Ikijen Em ak Jikin Jelelokjen

Students without fixed, regular, and adequate nighttime residences have the following rights:/Rijikul eo ejab tõt, ak oktaktak jikin an jokwe ewõr an maroñ kein:
1. Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations;/Emaroñ kaju drelone jikul eo ekar jikul ie ak jikul eo ilo bukon eo ej bed ie im ejab aikuj kõtar aolepen pepa ko raikuji ilo ien eo ej kane ñan jikul ilo ejjelok mijak ak uwõta ke renaj kõman ñane oktaklok jen ro jet kõn aban in ej bed ie;
2. Transportation to the school of origin for the regular school day;/Naaj maroñ lelok ñane ial ñan jikul ilo awa in jikul ko;
3. Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students./Ejjelok onen an mõñā, enaaj bed ilo Title I im brokram ko an jikin jelalokjen , im katak ko enaj bữki ejjelok oktak jen katak ko rijikul ro jet rej bữki.
Any questions about these rights can be directed to the local McKinney-Vento liaison at 870-892-4573 or the state coordinator at 501-683-5428./Aolep kajitõk ko ikijin maroñ kein an rijikul eo remaroñ kaju lok ñan McKinney-Vento liaison ak State Coordinator ilo numba in 501-683-5428.

By signing below, I acknowledge that I have received and understand the above rights./Ilo am sign i ijin ilal, kwõj kalikar ke emõj am bõk meļeļe im lukun jelā maroñ ko an rijikul eo.
Signature of Parent/Guardian/Unattached Youth/Jain i etan mama/baba ak ro rej lale rijkul eo

Clear
Date/Raan

Month Day Year
Date
Services for McKinney-Vento Identified Students
Student:/Etan rijikl eo:
School:/Jikul eo an:
Grade:/Kilaaj jete: *
Please check the services needed or desired:/Jouj im maaki jiban ko im rijul eo ej aikuji:

Free Lunch/Mona ilo ejjelok onen Transporation to the school of origin/ial jen kabijuknen eo Clothing/Uniform/Nuknuk/uniform School Supplies/Kein jikul Counseling/Jiban jen counselor ro Medical/Dental referral/Pepa nan docto ak koman ni Vision referral/Pepa nan koman mej Medicaid/DSHS services - food stamps Preschool Enrollment records/Preschool pepa Missing enrollment records/Rekot ko rejako nan ien drelon jijul Birth Certificate/Pepa in lotak Immunization/medical records/Pepa in docto/wa ko Tutoring/Tutor ak jiban ilo jikul After-school programs/Brokram ko mojin jikul Teen Center/Center eo an jiron im likao Mentoring/Rijiban ro Special Education/Jiban nan utamwe ro Gifted/talented/Brokram eo an GT Vocational/technical Community resource/Jiban ko ibelakin bukon/weto eo Prior academic records/Academic rekot ko LEP/Bilingual program/Rijiban ro rej kajin eo am Guardianship issues/Jiban ko ikijin ro rej lale rijkul eo
Signature of Parent/Guardian/Unattached Youth/Jain i etan mama/baba ak ro rej lale rijikul eo

Clear
Date/Raan

Month Day Year
Date
Should be Empty:

2020-2021 Residency Form