Student Residency Questionnaire

Please complete the form below. Required fields marked with an asterisk *

The goal of the Hoomeless Education Program is to effectively serve students and families in transition, providing advocacy and referral services that foster a sense of empowerment and stability. To determind if your child is eligible for these services, please complete the Student Residency Questionnaire. For additional information, please contact the main office of your child's school and ask to speak to Mrs. Salas.

Date*

Answer Required

School Site*

Answer Required

Breed Site

Second St Site

Eastman Site

Student(s) first and last name*

Answer Required

Student(s) Date of Birth*

Answer Required

Grade of Student(s)*

Answer Required

TK/K

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Parent Guardian First and Last Name*

Answer Required

Phone Number*

Number Required

Please list ALL sibilings between the ages of birth and 22 years old. Include their names, date(s) of birth, age, grade, and school of attendance*

Answer Required

The McKinney-Vento Homeless Assistance Act, part of No Child Left Behind, entitles all homeless school-aged children access to the same free, appropriate public education that is provided to non-homeless youth. Schools are required to remove barriers to the enrollment, attendance, and success of homeless students in school.

The Homeless Education Program may be able to provide assistance in the following areas. Please check areas of need, if any:*

Answer Required

School supplies

Clothing Assistance (shoes, clothing, uniforms)

Transportation assistance

Backpacks

Assistance for a Homeless Teen Parent

Hygiene Kits

Educational Advocacy

Other:

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Student Residency Questionnaire