Housing Questionnaire UTOPIAN ACADEMY FOR THE ARTS

The answers you give 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.

If you do not currently own or rent a home, where is the student currently living? Please check one box

In a motel A car, park, campsite, or similar location In a shelter Transitional Housing Other Moving from place to place/couch surfing In someone's else's house or apartment with another family In a residence with inadequate facilities no water, heat, electricity, etc

Have you been forced in or from your residence due to economic hardship or other hardship?

Yes No

Do you work in agriculture and does your residence depend on it?

Yes No

Name of Student

(Last)

Name of School

Grade

Student Date of Birth

Date

Age

Student is unaccompanied (not living with a parent or legal guardian) Student is living with a parent or legal guardian

ADDRESS OF CURRENT RESIDENCE

PHONE NUMBER OR CONTACT NUMBER

Area Code Phone Number

NAME OF CONTACT

*I declare under penalty of perjury under the law of the State of Georgia that the information provided here is true and correct.

Print name of parent(s)/legal guardian(s):

Print name of parent(s)/legal guardian(s): (Or unaccompanied youth)

Signature of parent/legal guardian *

Clear

Date

McKinney-Vento Act 42 U.S.C. 11435 SEC. 725 DEFINITIONS. For purposes of this subtitle: The terms enroll' and enrollment' include attending classes and participating fully in school activities. (1) The term homelesschildren and youths' a. Means individuals who lack a fixed, regular, and adequate nighttime residence (within the meaning of section 103(a) (1; and b. Includes i. Children and youths who are sharing the housing of other persons due to loss of housing, economic hardship, or similar reason; are living in motels, hotels, trailer parks, or camping grounds due to the lack of alternative adequate accommodations;arelivinginemergency or transitional shelters; are abandoned in hospitals; or are awaiting foster care placement; ii. Children and youths who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings (within the meaning of section 103(a2C; iii. Children and youths who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar setting; and iv. Migratory children (as such term is defined in section 1309 of the Elementary and Secondary Education Act of 1965) who qualify as homeless for the purpose of this subtitle because the children are living in circumstances described in clauses (i) through (iii (2) The term unaccompanied youth' includes a youth not in the physical custody of a parent or guardian. Additional Resources Parent information and resources can be found at the following: ttp://center.serve.org/nche/ibt/parent_res.php http://naehcy.org/educational-resources/naehcy-publications

Student Housing Questionnaire