Student Residency Questionnaire
Name of School
Name of Student
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine the services the student may be eligible to recieve.
1. Is your current address a temporary living arrangement?
2. Is this temporary living arrangement due to loss of housing or economic hardship?
If you answered YES to the above questions, please complete the remainder of this form. If you answered NO, you may stop here.
Where is the student presently living (Choose one)
In a motel
In a shelter
With more than one family in a house or apartment
Moving from place to place
In a place not designed for ordinary sleeping accommodations such as a car, park, or campsite
Name of Parent(s)/Legal Guardian(s)
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Presenting a false record or falsifying records is an offence under Section 37.10, Penal Code, and enrollment of the child under false documents subjects the person to liability or other cost.
Signature of Parent/Legal Guardian
Should be Empty: