PPS-F002 McKinney-Vento Residency and Eligibility Form

Please contact Pupil Personnel Services at 203-783-3410 prior to completing this form.

Milford Public Schools
McKinney-Vento Act
Residency, Eligibility and Educational Rights Information

The McKinney-Vento Homeless Assistance Act was created with the goal of ensuring the enrollment, attendance, and success of homeless children and youth in school.
The McKinney-Vento Act provides certain rights for homeless students. This includes waiving certain requirements such as proof of residency when students are enrolling and allowing eligibility for certain services, such as free textbooks.
When families and students find themselves in transition due to their housing situation, it is important that they know their rights regarding education. If students meet the requirements as stated in the McKinneyVento Act (42 U.S.C 11431 et seq., Title VII, Subtitle B), their rights are as follows:

Students may attend their school of origin or the school where they are temporarily residing.
Students may enroll without school, medical or similar records.
Students have a right to transportation to school.
Students must be provided a statement explaining why they are denied enrollment or any other services.
Students must receive services, such as transportation, while disputes are being settled. Students are automatically eligible for Title I services.
Students and families should receive referrals to health, dental, mental health, housing, substance abuse and other appropriate services.
Unaccompanied homeless youth are informed, and receive verification of their status as independent students for college financial aid, and
Barriers that prevent any homeless youth from receiving credit for full or partial course-work satisfactorily completed at a prior school

Educational services for which the homeless student meets eligibility criteria including services provided under Title 1 of the Elementary and Secondary Education Act or similar State or local programs, educational programs for students with limited English proficiency. According to the U.S. Department of Education, people living in the following situations are considered homeless:

Doubled up with family or friends due to loss of housing or economic hardship
Living in motels and hotels for lack of other suitable housing
Runaway and displaced children and youth – Unaccompanied Youth
Homes for unwed or expectant mothers for lack of a place to live
Homeless and domestic violence shelters
Transitional housing programs
The streets
Abandoned buildings
Public places not meant for housing
Cars, trailers (does not include mobile homes intended for permanent housing), and campgrounds
Migratory children staying in housing not fit for habitation

Questions may be directed to your Principal, Social Worker/School Counselor, or: Jennifer at Stewart at jstewart@milforded.org. You may also call (203)-783-3410

CONFIDENTIAL
Milford Public Schools
MCKINNEY-VENTO STUDENT RESIDENCY & ELIGIBILITY FORM

The following questions are intended to address the McKinney-Vento Homeless Education Assistance Act, 42 U.S.C. § 11431, et seq. Your answers to the following questions will aid school district staff to determine whether your child may be eligible for services under this Act. Please complete the entire form.

District Name*

School Name*

Student Name*

First NameLast Name

MaleFemale

Date of birth*

Date

Grade*

Contact Person*

First NameLast Name

ParentGuardianOther

Previous Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

RACE*

CONFIDENTIAL INFORMATION

ShelterMotel/hotel, camping ground or other similar situation due to lack of alternative, adequate housingTrain or bus station, park or in a carAbandoned apartment/buildingWith relatives or others due to lack of housingTemporarily housed in shelter awaiting DCFS foster care placementOtherDisaster victim?

Shelter Name*

Shelter Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Motel/hotel, camping ground or other similar situation due to lack of alternative, adequate housing name:*

Motel/hotel, camping ground or other similar situation due to lack of alternative, adequate housing name address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of relative or others you are staying with due to lack of housing*

First NameLast Name

Address of relative other others you are staying with due to lack of housing*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Temporarily housed in shelter awaiting DCFS foster care placement name:*

Temporarily housed in shelter awaiting DCFS foster care placement address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other (Please describe):*

Disaster victim? Please explain below:*

YesNo

Last school attended:*

Schoolname

Address of last school attended:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Eligible for any educational and school related activities and services?*

Possible Barriers to Education*

Please list below the children in your care:

Rows	Name of Child	Date of Birth	Male/Female	Grade Level	Name of last school attended	Name of new school
1
2
3
4
5
6
7
8
9
10

CONTACT INFORMATION OF FAMILY

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Emergency contacts*

Services already being provided (if none, please enter none)*

Other information

In signing this document, I understand and acknowledge that I am representing that my child is entitled to free school accommodations from the City of Milford by virtue of their having a legal residence at the abovenamed address. I understand that if the information provided in connection with this questionnaire is determined to be false or misleading, resulting in the child/children named above to not be legally entitled to attendance in the Milford Public Schools, the school district may take legal action to recoup valid tuition charges and legal fees. I understand that if it is determined that I have defrauded the Milford Public Schools, I may also be subjected to the pains and penalties of perjury and false statement and such other remedies as may be available under law.

Signature of Parent/Guardian*

Date*

Date