25-26 Project UP-START Program Student Eligibility Questionnaire

Miami-Dade County Public Schools Department of Title I Administration Project UP-START Program 2025-2026 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 the second degree.

Project UP-START Services are confidential and this form is not to be shared with outside agencies.
QUESTION 1: WHAT IS YOUR FAMILY CURRENT NIGHTTIME RESIDENCE? (SELECT ONE OPTION)

Shelter (A)Sharing the home of others/Double-up (B)Car/Park/Trailer/Substandard Housing e.g., no water, no electricity, mold infestation (D)Hotel/Motel/Airbnb (E)Rent home*Own home*
*If you select Rent Home/Own Home, please go to Question #7.
QUESTION 2: WHAT IS THE REASON YOUR FAMILY DOES NOT HAVE A PERMANENT NIGHTTIME RESIDENCE? (SELECT ONE OPTION)

Pandemic (P)Hurricane (H)Flooding (F)Lack of affordable housing/eviction, domestic violence, mental illness, unemployment, etc. (N)Parent/Caregiver is IncarceratedMan-Made Disaster (D)Mortgage Foreclosure (M)Tropical Storm (S)Tornado (T)Wildfire (W)Unknown (U)
QUESTION 3: WHO IS/ARE THE STUDENT(S) FOR WHOM YOU ARE COMPLETING THIS FORM?
Student First and Last Name - 1
Student 1 ID Number
Student 1 Date of Birth
Student 1 Grade Level
Student 1 School Name/Location #
Student First and Last Name - 2
Student 2 ID Number
Student 2 Date of Birth
Student 2 Grade Level
Student 2 School Name/Location #
Student 3 First and Last Name
Student 3 ID Number
Student 3 Date of Birth
Student 3 Grade Level
Student 3 School Name/Location #
Student 4 First and Last Name
Student 4 ID Number
Student 4 Date of Birth
Student 4 Grade Level
Student 4 School Name/Location #
Student 5 First and Last Name
Student 5 ID Number
Student 5 Date of Birth
Student 5 Grade Level
Student 5 School Name/Location #
QUESTION 4: ARE YOU SEEKING SUPPORT SERVICES FOR YOUR CHILD AT THIS TIME? (SERVICES ARE ONLY APPLICABLE TO ELIGIBLE FAMILIES)

Yes, I am requesting services at this time.*No, I am not requesting services at this time.
*If "Yes" is selected, your child's school will contact you to obtain information about the specific service(s) that you are seeking for your child.

Attention School Staff: Please submit a Referral for Services (FM-7404) and/or Transportation Request (FM-7405) if the family is requesting services.
QUESTION 5 AND 6: TO BE COMPLETED BY UNACCOMPANIED YOUTH ONLY (SELECT ONE OPTION)

5 Are you living alone without an adult?6 Are you living alone with an adult that is NOT a parent/guardian?
Caregiver's Name
Date

MonthDayYear
Date
Unaccompanied Youth Signature

Clear
Phone Number
*Please ask your caregiver to complete the Caregiver's Authorization Form (FM-7402), and submit it with this form.
QUESTION 7: WHAT IS YOUR ADDRESS/CONTACT INFORMATION?
Current Address
Length of time at Current Address
Former Address
Phone Number
Parent's Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Miami-Dade County Public Schools Department of Title I Administration Project UP-START Program 2025-2026 Project UP-START Student Eligibility Questionnaire

QUESTION 3: WHO IS/ARE THE STUDENT(S) FOR WHOM YOU ARE COMPLETING THIS FORM?

QUESTION 7: WHAT IS YOUR ADDRESS/CONTACT INFORMATION?