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Homeless_Intake

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					                                      Augusta County Public Schools
                                          Homeless Intake Form
School: __________________

Date School was notified child was homeless: __________________

Student’s Name: _______________________ Grade: ______________

Parent’s Name: __________________________________________

Temporary Address: _________________________
                     _________________________

Phone Number: (H/C)__________________________                      (W)__________________________

Sibling: _______________________________            School: ____________                 Grade:    __________

Sibling: _______________________________            School:_____________         Grade: __________

Sibling: _______________________________            School:_____________         Grade: __________

Living arrangements:

□ Shelter, Transitional housing                 □ Double-up (Living with another family, friend, etc.)

□ Unsheltered (car, campground, etc.)           □ Motel or Hotel


Date left previous residency? ____________________________

Reason for leaving: _________________________________________________

_________________________________________________________________

Expected length of stay at current residence: ____________________________

Is an agency currently assisting with locating permanent housing?

If yes, which agency ____________________

Completed by: ____________________________ Date: ____________

*PLEASE EMAIL THIS COMPLETED FORM TO YOUR SCHOOL SOCIAL WORKER

Verification of Homeless (to be completed by School Social Worker):

Date of Home Visit __________________ Is follow-up visit needed? _______________

□ Eviction notice □ Court order      □ Hospital/shelter/mental health agency/social services

□ Other _______________________________________________________________________

Is transportation needed? _________

If it is, complete transportation request, give to principal for signature and forward to school social worker/visiting
teacher

Completed by: ____________________________ Date: ____________

*PLEASE EMAIL THIS COMPLETED FORM BACK TO THE ENROLLMENT PERSONNEL

				
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