STUDENT RESIDENCY QUESTIONNAIRE
Please complete this form if the student is NOT living with parent(s) or legal guardian(s) to help
identify who is homeless as required by the McKinney-Vento Homeless Education Assistance
Improvement Act, 42 U.S.C.11435. The answers to this residency information help determine the
services the student may be eligible to receive.
1. Presently, where is the student living? Check one box:
□ Sharing the housing of other persons due to loss of housing, economic hardship, or a
similar reason (other than parent/guardian)
□ In a shelter, abandoned in hospital; or awaiting foster care placement
□ In a motel, car, campsite or similar settings
2. The student lives with:
□ A relative, friend(s) or other adult(s)
□ Alone with no friends
□ An adult that is not the parent or legal guardian
Name of Student: _________________________________________________________
Last First Middle
Birth Date: ______/____/_____ Age: _________ Male Female
Month / Day / Year
Social Security #: ___________________
Name of Parent(s)/Legal Guardians(s): ____________________________________________
Address: ___________________________________ Zip: __________ Phone: _____________
Signature of Parent/Legal Guardian:____________________________________ Date:______
Presenting a false record or falsifying records is an offense under Section 37.10, Penal code, and enrollment of the
child under false documents subjects the person to liability for tuition or other costs. TEC Sec. 25.002(3)( d).
School use only – Campus Administrator’s determination of Section A circumstance:
□ Student lives apart from parent/guardian for school purposes.
□ Student and parent live with another family – not homeless.
□ Student comes under the McKinney Act.
Instructions for campus personnel:
Instructions for Registrars:
1. Mark in PEIMS as appropriate.
2. Send questionnaire to campus administrator and District PEIMS Coordinator
3. Keep a file of all questionnaires of homeless students.
FISD PEIMS 461-1