Residency Form
Your answers will help determine if the student meets eligibility requirements for services under the McKinney-Vento Act.
List all of your children birth through age 21
Child #1
*
Name of Child
School
Age
Grade
Date of Birth (including Year)
Child #2
Name of Child
School
Age
Grade
Date of Birth (including Year)
Child #3
Name of Child
School
Age
Grade
Date of Birth (including Year)
Child #4
Name of Child
School
Age
Grade
Date of Birth (including Year)
Child #5
Name of Child
School
Age
Grade
Date of Birth (including Year)
Parent or Guardian Information
Parent or Guardian Name
Address
City
Zip Code
Phone Number
Please enter a valid phone number.
In this address
Permanent - own your own home, or your name is on the lease of the apartment or house you are renting
Temporary - Temporary–staying in a hotel/motel/Shelter, transitional program, living with another individual or family due to financial hardship, or sleeping in a car, park,public place, or abandoned building.
If temporary, please check which of the following situations the student currently lives in (you can choose more than one):
Motel, car, or campsite
Shelter or other temporary housing
Living in inadequate housing (no heat, no water, mold infested, etc.)
*Shared housing with friends or family members (other than or inaddition to parent/guardian)
If you are living in shared housing, please check all of the following reasons that apply:
Loss of housing due to economic hardship
Loss of housing due to house/apartment fire
Temporarily waiting for house or apartment
Provide care for a family member
Living with boyfriend/girlfriend
Loss of employment
Parent/Guardian is deployed
Other (Please explain)
If other, please describe
Are you a student living apart from your parents or guardians?
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
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