RESIDENCY FORM 24v7

RESIDENCY FORM 24v7
Your answers will help determine if the student meets the eligibility requirements for services under the McKinney-Vento Act. List all of your children from birth through age 21.
Do you need translation services?

Yes, I need translation Services
Translation Services Needed
Do you speak Spanish?

YesNo
Spanish
Please select how many children you have
Child #1 Name
Child #1 Date Of Birth

MonthDayYear
Date
Child #1 School
Child #1 Age
Child #1 Grade
Child #2 Name
Child #2 School
Child 2 Age
Child #2 Grade
Child 2 Date of Birth
Child #3 Name
Child #3 School
Child #3 Age
Child #3 Grade
Child #3 Date of Birth
Child #4 Name
Child #4 School
Child #4 Age
Child #4 Grade
Child #4 Date of Birth
Child #5 Name
Child #5 School
Child #5 Age
Child #5 Grade
Child #5 Date of Birth
Parent/Guardian
Address
City
Zip Code
Phone Number(s)
Email
example@example.com
Is this address:

Permanent -- own your home, or your name is on the lease of the apartment or house you are rentingTemporary -- 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 campsiteShelter or other temporary housingLiving in inadequate housing (no heat, no water, mold-infested, etc.)Shared housing with friends or family members (other than or in addition 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 hardshpLoss of housing due to house/ apartment fireTemporarily waiting for house or apartmentProvide care for a family memberLiving with boyfriend/girlfriendLoss of employmentParent/Guardian is deployedOther
Other (Please explain)
Are you a student living apart from your parents or guardians?

YesNo

Housing and Educational Rights

Students without fixed, regular, and adequate nighttime residences have the following rights:
1. Immediate enrollment in the school they last attended or the local school where they are currently staying even if they do not have all of the documents normally required at the time of enrollment without fear of being separated or treated differently due to their housing situations
2. Transportation to the school of origin for the regular school day
3. Access to free meals, Title I and other educational programs, and transportation to extra-curricular activities to the same extent that it is offered to other students.
Any questions about these rights can be directed to the following:
- Vicky Simpson, LRSD Homeless/McKinney-Vento Liaison: 501-447-2930
- Jana Hunter, LRSD Family Service Liaison: 501-447-3339
- Marisol Canchola, LRSD Bilingual Family Service Liaison: 501-447-3361
- David Terrell, State McKinney-Vento contact: 501-534-3896
Arkansas law provides that anyone who knowingly gives a false residential address for purposes of public school enrollment is guilty of a violation and subject to a fine of up to $1,000 (Ark. Code Ann. § 6-18-202(f))

By signing below, I acknowledge that I have received and understand the above rights.
Signature of Parent/Guardian/Unattached Youth

Clear
Date

MonthDayYear
Date
Signature of McKinney Vento Liaison

Clear
Date

MonthDayYear
Date
Should be Empty: