FM7378 Project UP-START

Miami-Dade County Public Schools

Department of Title I Administration

Children and Youth in Transition Program

2021-2022 Project UP-START Student Eligibility Questionnaire

This questionnaire is intended to help determine eligibility of services under the federal McKinney-Vento Act. Florida Statute 837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of second degree.

Project UP-START services are confidential and this form is not to be shared with outside community agencies.

SECTION A: The student currently has housing that is Fixed, Regular, and Adequate.
Parent/Guardian Initial*
Student Name*
Student ID#*
Please note that if you check either box below, your child does not qualify for Project UP-START.

Rent/own your homeLive in foster care placement
If none of the boxes above are checked, please complete the next section.
SECTION B: The student does NOT currently have housing that is Fixed, Regular, and Adequate.

Please continue below if your child is a student that:
The current nighttime residence is... (check only one)

In emergency or transitional shelters, FEMA trailers, or abandoned in hospitalsTemporarily sharing the housing of other persons due to economic hardshipLiving in a vehicle of any kind, trailer park or campground, parks, abandoned buildings, public place, or substandard housing (e.g. no running water no electricity/mold infested)In a motel/hotel due to loss of housing, economic hardship, or similar reason
Was displaced from household because of... (check only one)

PandemicNatural Disaster - HurricaneNatural Disaster - FloodingNatural Disaster - Tropical StormNatural Disaster - TornadoMan-made Disaster/FireMortgage ForeclosureLack of affordable housing, eviction, mental illness, unemployment, domestic violenceParents/Caregiver is incarceratedUnknown/Other

Please list the names of all students who are active in M-DCPS

	Student Name (Last, First)	Student ID#	Date of Birth	Grade	School/Location #

Current Address
Apt
City
Zip
Contact Phone
Email
example@example.com
Name of Parent/Guardian
Date

MonthDayYear
Date
Section C: Unaccompanied Youth must complete this section, prior to submitting the Questionnaire for processing. The undersigned certifies that the information provided is accurate.

Student is living alone without an adult.Student is living with an adult that is NOT a parent/guardian.
Caregiver Name
Please complete the FM-7402 (Caregiver's Authorization Form).
SECTION D: Parents, Guardians and/or Unaccompanied Youth must complete this section, prior to submitting the Questionnaire for processing.

The undersigned certifies that the information provided is accurate.
Signature of Parent/Guardian OR Unaccompanied Student*

Clear
Date*

MonthDayYear
Date
Should be Empty: