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STUDENT RESIDENCY QUESTIONNAIRE

This document is intended to address the McKinney-Vento Assistance Act.

Your answers will help determine documents necessary to enroll your child quickly.

Student: __________________________ Male or Female: _________________

Birthday: __________________ Grade: ____________ School: ______________

PLEASE CIRCLE ALL THAT APPLY

1.   Do you and your student live in a fixed, regular, adequate nighttime residence?

Yes or No

2.  Do you and the student live in:

A.     Shelter (other than a home or apartment)

B.     Motel/hotel

C.     Temporarily with another family in a house, mobile home, or apartment due to financial necessity

D.    In a car or RV

E.     At a campsite

F.     Transitional housing

G.    Other______________________________

3. The student lives with:

A.     One parent

B.     Two parents

C.     A qualified relative

D.    Friend(s)

E.     An adult that is not the legal guardian

F.     Alone with no adult(s)

4. I     am:

A.     The parent/legal guardian of the above-named student

B.     A qualified adult relative of the above-named student

(Relationship: ___________________________________________________)

I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge.

Signature: ___________________________________________Date: _____________

Print Your Name________________________________________________________

Residence: ____________________________________________________________

                     Street                                                                                                                           City                                         Zip

Mailing Address: _______________________________________________________

                                 Street                                                                                                                City                                         Zip         

Telephone: (     )_______________________ Cell: (     )_________________________