Student Residency Questionnaire
Name of School
*
Name of Student
*
First Name
Middle Name
Last Name
Sex
*
Male
Female
Birth Date
*
-
Month
-
Day
Year
Age
*
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?
*
Yes
No
2. Is this temporary living arrangement due to loss of housing or economic hardship?
*
Yes
No
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)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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
Date
-
Month
-
Day
Year
Submit
Should be Empty: