Impact Aid Survey 2012-2013

Section I: Eligibility

All information entered should be based on your student's status as of September 30, 3012. All information will be kept confidential and only totals will used for federal reporting purposes.

1. As a parent/guardian of one or more Roanoke City Public School students indicate which applies to you (check either yes or no for each item listed):

	Yes	No
Live on Federal Property	*As a parent/guardian of one or more Roanoke City Public School students indicate which applies to you (check either yes or no for each item listed): Live on Federal Property Yes	Live on Federal Property No
Work on Federal Property	Work on Federal Property Yes	Work on Federal Property No
Currently on Active Military Duty	Currently on Active Military Duty Yes	Currently on Active Military Duty No

2. If either one or both parents/guardians live on federal property, enter the name and address of the federal property, otherwise leave blank.

If either one or both parents/guardians live on federal property, enter the name and address of the federal property, otherwise leave blank. Company:
Address:
Address 2:
City/Town:
State:
ZIP:

3. If either one or both parents/guardians work on federal property, enter the name and address of the federal property, otherwise leave blank.

If either one or both parents/guardians work on federal property, enter the name and address of the federal property, otherwise leave blank. Company:
Address:
Address 2:
City/Town:
State:
ZIP: