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Homeless Questionnaire by e00Dgg

VIEWS: 54 PAGES: 2

									                Please complete and return to the drop box outside the main office during
                           conferences and open houses on August 30 & 31


                               2011-2012
                   STUDENT RESIDENCY QUESTIONNAIRE
                           McKinney-Vento Homeless Assistance Act
                                Alden-Conger School District
This questionnaire is intended to address the McKinney-Vento Homeless Assistance Act 42 U.S.C.§11435 et seq. The
answers to this residency information will help determine the services this student may be eligible to receive. All
information obtained for this purpose will remain confidential. If a false claim is made about records or living
situation, the student may be liable for tuition or other costs.

Please check one:          □ Not Homeless- thank you for completing this questionnaire
                           □ In Transition – sheltered, but not living with parent or legal guardian
                                          (OR entire family “doubling-up” with another family)
                           □   Homeless – unsheltered (living in car, park, or other temporary shelter
                                                  with or without parent or legal guardian)


School Name:                                                          Date:

Student Name:                                                         Birthdate:

Age:              Grade:             Student #:              Emergency Phone #:

Siblings:

Parent/Legal Guardian:

Address:                                              City:                          Zip Code:

Home Phone #: (       )                 Work #: (      )                      Cell #: (   )

Person student is currently living with (if different than parent or legal guardian):

Relationship to Student:

Address:                                             City:                         Zip Code:

Home Phone #: (       )                 Work #: (      )                      Cell #: (   )




<<< Please continue filling out this form on the other side.
Please check the box that applies to where the student is presently living:

□ Student is sharing housing with other persons due to loss of housing, economic hardship, or similar
  reason.
□ Student is living in an emergency or transitional shelter (domestic violence, emergency, or transitional
  housing unit.
□ Student is living in a motel, hotel, trailer park, or camping grounds due to lack of adequate alternative
  accommodations.
□ Student is living in a car, park, abandoned building, public building, substandard housing (lack of
  running water, heat, electricity), bus or train station, or a similar setting.
□ Student is seeking enrollment without an accompanying parent (not in physical custody of parent,
  guardian, and not living in foster care).
□ Student is a migratory child living in conditions described in previous examples.
□ Student is living in a transitional housing program.




Parent(s), Guardian(s) or Student:
       Please notify school if your living status changes.
       Please contact Amy Wallin, Alden-Conger School District’s Educational Homeless
           Liaison, (McKinney-Vento Act), at (507)874-3240, if you have questions or concerns
           about a homeless situation.
       Would you like to receive additional information from the Educational Homeless
           Liaison? □ Yes            □ No

School:
       Fax to (507)874-2747 or return forms that indicate temporary residence to Amy Wallin,
        Alden-Conger School District’s Educational Homeless Liaison (McKinney-Vento Act).

								
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